Client’s Handbook
Problem Gambling Integrated Matrix Intensive Outpatient Treatment for People With Stimulant Use Disorders
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment 1 Choke Cherry Road Rockville, MD 20857
Acknowledgments Numerous people contributed to this document, which is part of the Methamphetamine Treatment Project (MTP). The document was written by Jeanne L. Obert, M.F.T., M.S.M.; Richard A. Rawson, Ph.D.; Michael J. McCann, M.A.; and Walter Ling, M.D. The MTP Corporate Authors provided valuable guidance and support on this document. This publication was developed with support from the University of California at Los Angeles (UCLA) Coordinating Center through Grant No. TI11440. MTP was funded by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (DHHS). The research was conducted from 1998 to 2002 in cooperation with the following institutions: County of San Mateo, San Mateo, CA (TI11411); East Bay Recovery Project, Hayward, CA (TI11484); Friends Research Institute, Inc., Concord, CA (TI11425); Friends Research Institute, Inc., Costa Mesa, CA (TI11443); Saint Francis Medical Center of Hawaii, Honolulu, HI (TI11441); San Diego Association of Governments, San Diego, CA (TI11410); South Central Montana Regional Mental Health Center, Billings, MT (TI11427); and UCLA Coordinating Center, Los Angeles, CA (TI11440). The publication was produced by JBS International, Inc. (JBS), under Knowledge Application Program (KAP) contract numbers 270-99-7072 and 270-04-7049 with SAMHSA, DHHS. Christina Currier served as the CSAT Government Project Officer. Andrea Kopstein, Ph.D., M.P.H., served as the Deputy Government Project Officer. Cheryl Gallagher, M.A., served as CSAT content advisor. Lynne MacArthur, M.A., A.M.L.S., served as JBS KAP Executive Project Co-Director; Barbara Fink, RN, M.P.H., served as JBS KAP Managing Project Co-Director; and Emily Schifrin, M.S., and Dennis Burke, M.S., M.A., served as JBS KAP Deputy Directors for Product Development. Other JBS KAP personnel included Candace Baker, M.S.W., Senior Writer; Elliott Vanskike, Ph.D., Senior Writer; Wendy Caron, Editorial Quality Assurance Manager; Frances Nebesky, M.A., Quality Control Editor; Pamela Frazier, Document Production Specialist; and Claire Speights, Graphic Artist.
Disclaimer The opinions expressed herein are the views of the authors and do not necessarily reflect the official position of CSAT, SAMHSA, or DHHS. No official support of or endorsement by CSAT, SAMHSA, or DHHS for these opinions or for particular instruments, software, or resources described in this document is intended or should be inferred. The guidelines in this document should not be considered substitutes for individualized client care and treatment decisions.
Public Domain Notice All materials appearing in this volume except those taken directly from copyrighted sources are in the public domain and may be reproduced or copied without permission from SAMHSA/CSAT or the authors. Do not reproduce or distribute this publication for a fee without specific, written authorization from SAMHSA’s Office of Communications.
Electronic Access and Copies of Publication Copies may be obtained free of charge from SAMHSA’s National Clearinghouse for Alcohol and Drug Information (NCADI), 800-729-6686 or 240-221-4017; TDD (for hearing impaired) 800-487-4889; or electronically through www.ncadi.samhsa.gov. Copies may be downloaded from www.kap.samhsa.gov.
Recommended Citation Center for Substance Abuse Treatment. Client’s Handbook: Matrix Intensive Outpatient Treatment for People With Stimulant Use Disorders. DHHS Publication No. (SMA) 07-4154. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2006, reprinted 2007.
Originating Office Practice Improvement Branch, Division of Services Improvement, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857. DHHS Publication No. (SMA) 07-4154 Printed 2006 Reprinted 2007
Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Individual/Conjoint Session Handouts IC 1—Sample Service Agreement and Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 IC 2A—Recovery Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 IC 2B—Relapse Analysis Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 IC 3A—Treatment Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 IC 3B—Continuing Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Early Recovery Skills Handouts SCH 1—The Importance of Scheduling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 SCH 2—Daily/Hourly Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 CAL 1—Marking Progress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 CAL 2—Calendar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 ERS 1A—Triggers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 ERS 1B—Trigger–Thought–Craving–Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 ERS 1C—Thought-Stopping Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 ERS 2A—External Trigger Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 ERS 2B—External Trigger Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 ERS 3A—Internal Trigger Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 ERS 3B—Internal Trigger Chart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 ERS 4A—12-Step Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 ERS 4B—The Serenity Prayer and the 12 Steps of Alcoholics Anonymous . . . . . . . . . . . . . . 28 ERS 5—Roadmap for Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 ERS 6A—Five Common Challenges in Early Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 ERS 6B—Alcohol Arguments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 ERS 7A—Thoughts, Emotions, and Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 ERS 7B—Addictive Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 ERS 8—12-Step Sayings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Relapse Prevention Handouts RP 1—Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 RP 2—Boredom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
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Client’s Handbook: Matrix Intensive Outpatient Treatment RP 3A—Avoiding Relapse Drift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 RP 3B—Mooring Lines Recovery Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 RP 4—Work and Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 RP 5—Guilt and Shame . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 RP 6—Staying Busy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 RP 7—Motivation for Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 RP 8—Truthfulness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 RP 9—Total Abstinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 RP 10—Sex and Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 RP 11—Anticipating and Preventing Relapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 RP 12—Trust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 RP 13—Be Smart, Not Strong . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 RP 14—Defining Spirituality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 RP 15—Managing Life; Managing Money . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 RP 16—Relapse Justification I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 RP 17—Taking Care of Yourself . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 RP 18—Emotional Triggers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 RP 19—Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 RP 20—Recognizing Stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 RP 21—Relapse Justification II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 RP 22—Reducing Stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 RP 23—Managing Anger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 RP 24—Acceptance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 RP 25—Making New Friends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 RP 26—Repairing Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 RP 27—Serenity Prayer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 RP 28—Compulsive Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 RP 29—Coping With Feelings and Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 RP 30—12-Step Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 RP 31—Looking Forward; Managing Downtime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 RP 32—One Day at a Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 RP 33—Drug Dreams During Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 RP Elective A—Client Status Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 RP Elective B—Holidays and Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 RP Elective C—Recreational Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
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Introduction Welcome You have taken a big step by deciding to come into treatment. You should be very proud of your decision to enter treatment and your commitment to recovery. This is your Client’s Handbook. It contains most of the handouts you will need for your treatment. In this book you will find handouts for three types of sessions: Individual/ Conjoint, Early Recovery Skills, and Relapse Prevention. Family Education sessions also use handouts. Those handouts will be given to you by your counselor during the Family Education sessions.
Client Handouts The handouts in this book will help you get the most out of your Matrix treatment. Some handouts ask questions and have spaces for your answers. Other handouts ask you to read and think about a subject or an idea, or they contain advice or reminders about recovery. It is a good idea to keep and review the handouts after you have used them. They will help you stay strong as you continue in your recovery. During each treatment session, your counselor will ask you to follow along on the handout while he or she goes over it with the group. The counselor will give you time to think about what it says and write your answers to questions it may ask. The group will then discuss the handout. You should share your thoughts and ask questions during this time. If you still have questions, there will be more time to ask questions during the last part of each session.
Making the Most of Group Sessions The more work you put into group therapy, the more benefit you will receive from it. Part of the work you should be doing is reading and thinking about the handouts. But there are other things you can do to make sure you benefit fully from group therapy:
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Client’s Handbook: Matrix Intensive Outpatient Treatment
Attend every group session. Arrive for group sessions on time or a little early. Listen carefully and respectfully to the counselor and the other clients. Be supportive of other clients. If you disagree with someone, be polite when you speak to him or her. Do not attack people personally. Do not talk about other clients’ personal information outside group. Clients must be able to trust one another if they are to feel comfortable sharing their thoughts. Think about what you read and about what the counselor and other clients say. Ask questions when you do not understand something. Participate in group discussions. Do not dominate the conversation. Allow time for other clients to participate. Be honest. After the session is over, think about what you learned and try to apply it to your recovery. Work on the homework assignments that the counselor gives you. (The homework assignments are usually an activity. These are different from the handouts that you work on during the session.)
2
IC 1
Sample Service Agreement and Consent
[Each program uses an agreement and consent form that it has developed to meet its particular needs. This form is provided as a sample.] It is important that you understand the kinds of services you will be provided and the terms and conditions under which these services will be offered. I,
, am requesting treatment from the staff of . As a condition of that treatment, I acknowledge the following items and agree to them. (Please initial each item.)
I understand: 1. The staff believes that the outpatient treatment strategies the program uses provide a useful intervention for chemical dependence problems; however, no specific outcome can be guaranteed. 2. Treatment participation requires some basic ground rules. These conditions are essential for a successful treatment experience. Violation of these rules can result in treatment termination.
I agree to the following: a. It is necessary to arrive on time for appointments. At each visit I will be prepared to take urine and breath-alcohol tests. b. Conditions of treatment require abstinence from all drug and alcohol use for the entire duration of the treatment program. If I am unable to make this commitment, I will discuss other treatment options with the program staff. c. I will discuss any drug or alcohol use with the staff and group while in treatment. d. Treatment consists of individual and group sessions. Individual appointments can be rescheduled, if necessary. I understand that group appointments cannot be rescheduled and attendance is extremely important. I will notify the counselor in advance if I am going to miss a group session. Telephone notification may be made for last-minute absence or lateness. e. Treatment will be terminated if I attempt to sell drugs or encourage drug use by other clients. f. I understand that graphic stories of drug or alcohol use will not be allowed.
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3
IC 1
Sample Service Agreement and Consent
g. I agree not to become involved romantically or sexually with other clients. h. I understand that it is not advisable to be involved in any business transactions with other clients. i. I understand that all matters discussed in group sessions and the identity of all group members are absolutely confidential. I will not share this information with nonmembers. j. All treatment is voluntary. If I decide to terminate treatment, I will discuss this decision with the staff. 3. Staff: Services are provided by psychologists, licensed marriage and family counselors, master’s-level counselors-in-training, or other certified addiction staff people. All nonlicensed counselors are supervised by a licensed counselor trained in the treatment of addictions. 4. Consent to Videotape/Audiotape: To help ensure the high quality of services provided by the program, therapy sessions may be audiotaped or videotaped for training purposes. The client and, if applicable, the client’s family consent to observation, audiotaping, and videotaping. 5. Confidentiality: All information disclosed in these sessions is strictly confidential and may not be revealed to anyone outside the program staff without the written permission of the client or the client’s family. The only exceptions are when disclosures are required or permitted by law. Those situations typically involve substantial risk of physical harm to oneself or to others or suspected abuse of children or the elderly. 6. Accomplishing treatment goals requires the cooperation and active participation of clients and their families. Very rarely, lack of cooperation by a client may interfere substantially with the program’s ability to render services effectively to the client or to others. Under such circumstances, the program may discontinue services to the client.
I certify that I have read, understand, and accept this Service Agreement and Consent. This agreement and consent covers the length of time I am involved in treatment activities at this facility.
Client’s Signature:
4
Date:
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IC 2A
Recovery Checklist
Outpatient treatment requires a great deal of motivation and commitment. To get the most from treatment, it is necessary for you to replace many old habits with new behaviors.
Check all the things that you do regularly or have done since entering treatment: Schedule activities daily
Avoid triggers (when possible)
Visit physician for checkup
Use thought stopping for cravings
Destroy all drug paraphernalia
Attend Individual/Conjoint sessions
Avoid people who use alcohol Avoid people who use drugs
Attend Early Recovery Skills and Relapse Prevention sessions
Avoid bars and clubs
Attend 12-Step or mutual-help meetings
Stop using alcohol
Get a sponsor
Stop using all drugs
Exercise daily
Pay financial obligations promptly
Discuss thoughts, feelings, and behaviors honestly with your counselor Look at the impact of gambling on my recovery
Identify addictive behaviors
What other behaviors have you decided to start since you entered treatment?
Which behaviors have been easy for you to do?
Which behaviors take the most effort for you to do?
Which behavior have you not begun yet? What might need to change for you to begin this behavior? Behavior Not Begun
Change Needed
5
6
Date of Relapse:
A relapse episode does not begin when you take a drug or gamble. Often, things that happen before you use indicate the beginning of a relapse. Identifying your patterns of behavior will help you recognize and interrupt the relapse. Using the chart below, note events that occurred during the
IC 2B
Name:
week immediately before the relapse.
Personal Events
Treatment Events
Feelings about the above events
Relapse Thoughts
Health Status
Relapse Analysis Chart
Career Events
Drug/Gam blingBehavioral Related Patterns Behaviors
Recovery requires specific actions and behavioral changes in many areas of life. Before you end your develop a plan and identify the steps necessary for reaching your goals. Write your current status and goals for the areas of life listed in the left column.
Subject
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Work/Career
Friendships
Financial, Legal Obligations
Where would you like to be?
What steps do you need to take?
When?
Treatment Evaluation
Family
Where are you now?
IC 3A
treatment, it is important to set new goals and plan for a different lifestyle. This guide will help you
7
8 Where would you like to be?
What steps do you need to take?
When?
Education
IC 3A
Subject
Where are you now?
Exercise
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Gambling
12-Step or Mutual-Help Meetings
Client’s Signature
Date
Counselor’s Signature
Date
Treatment Evaluation
Leisure Activities
IC 3B
Continuing Treatment Plan
Recovery is a lifelong process. You can stop drug and alcohol use and begin a new lifestyle during the first 4 months of treatment. Developing an awareness of what anchors your recovery is an important part of that process. Also considering the impact of behaviors such as gambling as relapse triggers or as potential new addictions, can strengthen your recovery.
But this is
only the beginning of your recovery. As you move forward with your recovery after treatment, you will need a lot of support. And you may need different kinds of support than you did during treatment. You and your counselor can use the information below to help you decide how best to support your recovery.
Gro up Work should participate in at least one regular recovery p every week after treatment. The program offers a ocial Support group that meets once a week. Other recovery groups are often available in the community. Ask your counselor about local recovery groups.
Individual Therapy Individual sessions with an addiction counselor might be helpful. When your current treatment ends, you have choices about continuing with therapy. You may choose this time to enter therapy with another professional. You may want to return to therapy with the professional who referred you for the Matrix IOP method. Or you may choose to continue to see your current Matrix IOP counselor.
Couples Therapy It is often a good idea at this point for couples to begin seeing a marriage counselor together to work on relationship issues.
12-Step or Mutual-Help Meetings Attendance at a 12-Step or mutual-help meeting is a critical part of the recovery process. It is essential to find a meeting that you will attend regularly.
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IC 3B
Continuing Treatment Plan
My plan for the months following treatment is:
Client’s Signature
Date
Counselor’s Signature
Date
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SCH 1
The Importance of Scheduling
Scheduling may be a difficult and boring task if you’re not used to it. It is, however,
What if I Am Not an Organized Person?
an important part of the recovery
Learn to be organized. Buy a schedule
process. People with substance use and
book and work with your counselor.
or gambling disorders do not schedule
Thorough scheduling of your activities is
their time. Scheduling your time will help
very important to treating your substance
you achieve and maintain abstinence.
use disorder. Remember, your rational brain plans the schedule. If you follow
Why Is Scheduling Necessary?
the schedule, you won’t use. Your addict-
If you began your recovery in a hospital,
ed brain wants to be out of control. If you
you would have the structure of the
go off the schedule, your addicted brain
program and the building to help you
may be taking you back to using drugs,
stop using. As a person in outpatient
drinking or gambling.
treatment, you have to build that structure to help support you as you continue
Who Decides What I Schedule?
functioning in the world. Your schedule
You do! You may consider suggestions
is your structure.
made by your counselor or family members, but the final decision is yours. Just
Do I Need To Write Down My Schedule?
be sure you do what you wrote down.
Absolutely. Schedules that are in your
any changes.
Follow your schedule; try not to make
head are too easily revised. If you write down your schedule while your rational
Most people can schedule a 24-hour
brain is in control and then follow the
period and follow it. If you can, you are
schedule, you will be doing what you
on your way to gaining control of your
think you should be doing instead of
life. If you cannot, you may need to con-
what you feel like doing.
sider a higher level of care as a start.
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SCH 2
Daily/Hourly Schedule
Date: 7:00 AM
How many hours will you sleep?
8:00 AM
From
To
9:00 AM 10:00 AM
Notes:
11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM
12
Reminders:
CAL 1
Marking Progress
It is useful for both you and your counselor to know where you are in the recovery process at all times. Marking a calendar as you go helps in several ways: It’s a reminder of how far you’ve come in your recovery. A feeling of pride often results from seeing the number of days you have been abstinent. Recovery can seem very long unless you can measure your progress in short units of time. Make a mark to record on the calendar pages every day of abstinence you achieve. You may decide to continue the exercise following the program. If you record your abstinent days regularly, this simple procedure will help you and your counselor see your progress.
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CAL 2
Calendar
Month: SUNDAY
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MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
Trigger
ERS 1A
Triggers
Use
Thought Craving
Triggers are people, places, objects, feelings, and times that cause cravings. For example, if every Friday night someone cashes a paycheck, goes out with friends, and uses stimulants and/or gambles, the triggers might be Friday night
After work
Friends who use
A bar or club
Money
Your brain associates the triggers with substance use and/or gambling. As a result of constant trigger- ing and using, one trigger can cause you to move toward substance use or gambling. Additionally one addictive behavior can be a trigger for another. Gambling may be a trigger for substance use just as substance use may be a trigger for gambling. The trigger–thought–craving–use cycle feels overwhelming. Stopping the craving process is an important part of treatment. The best way to do that is to do the following: 1.
Identify triggers.
2.
Prevent exposure to triggers whenever possible (for example, do not handle large amounts of cash).
3.
Cope with triggers differently than in the past (for example, schedule exercise and a 12-Step or mutual-help meeting for Friday nights).
Remember, triggers affect your brain and cause cravings even though you have decided to stop substance use or gambling. Your intentions to stop must translate into behavior changes, which keep you away from possible triggers.
What are some of the strongest triggers for you?
What particular triggers might be a problem in the near future?
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ERS 1B Trigger–Thought–Craving–Use The Losing Argument If you decide to stop drinking, using or gambling, but at some point end up moving toward using substances or gambling, your brain has given you permission by using a process called relapse justification. Thoughts about using or gambling start an argument inside your head—your rational self versus your substance/gambling dependent self. You feel as though you are in a fight, and you must come up with many reasons to stay abstinent. Your mind is looking for an excuse to use or gamble again. You are looking for a relapse justification. The argument inside you is part of a series of events leading to substance use or gambling. How often in the past has your substance or gambling dependence lost this argument?
Thoughts Become Cravings Craving does not always occur in a straightforward, easily recognized form. Often the thought of using or gambling passes through your head with little or no effect. But it’s important to identify these thoughts and try to eliminate them. It takes effort to identify and stop a thought. However, allowing yourself to continue thinking about substance use or gambling is choosing to relapse. The further the thoughts are allowed to go, the more likely you are to relapse.
The “Automatic” Process During addiction, triggers, thoughts, cravings, and use seem to run together. However, the usual sequence goes like this:
TRIGGER THOUGHT CRAVING
USE
Thought Stopping The only way to ensure that a thought won’t lead to a relapse is to stop the thought before it leads to craving. Stopping the thought when it first begins prevents it from building into an overpowering craving. It is important to do it as soon as you realize you are thinking about using or gambling.
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Thought-Stopping Techniques
ERS 1C A New Sequence
To start recovery, it is necessary to interrupt the trigger–thought–craving–use sequence. Thought stopping provides a tool for disrupting the process.
ThoughtStopping Techniques Trigger
Thought Continued Thoughts
Cravings
Addictive Behavior
This process is not automatic. You make a choice either to continue thinking about engaging in an addictive behavior (and start on the path toward relapse) or to stop those thoughts.
Thought-Stopping Techniques Try the techniques described below, and use those that work best for you:
Visualization. Imagine a scene in which you deny the power of thoughts of use or gambling. For example, picture a switch or a lever in your mind. Imagine yourself actually moving it from ON to OFF to stop the using or gambling thoughts. Have another picture ready to think about in place of those thoughts.
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ERS 1C
Thought-Stopping Techniques Snapping. Wear a rubberband loosely on your wrist. Each time you become aware of thoughts of using or gambling, snap the rubberband and say, “No!” to the thoughts as you make yourself think about another subject. Have a subject ready that is meaningful and interesting to you.
Relaxation. Feelings of hollowness, heaviness, and cramping in the stomach are cravings. These often can be relieved by breathing in deeply (filling lungs with air) and breathing out slowly. Do this three times. You should be able to feel the tightness leaving your body. Repeat this whenever the feeling returns.
Call someone. Talking to another person provides an outlet for your feelings and allows you to hear your thinking process. Have phone numbers of supportive, available people with you always, so you can use them when you need them.
ALLOWING THE THOUGHTS TO DEVELOP INTO CRAVINGS IS MAKING A CHOICE TO REMAIN DEPENDENT ON SUBSTANCES OR GAMBLING.
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ERS 2A
External Trigger Questionnaire
Place a checkmark next to activities, situations, or settings in which you frequently used substances or; place a zero next to activities, situations, or settings in which you never have used substances Home alone
During a date
Before going out to
Home with friends
Before sexual activities
dinner
Friend’s home
During sexual activities
Parties
After sexual activities
Sporting events
Before work
Movies
When carrying money
Bars/clubs
After going past dealer’s residence
Playing cards
Concerts With friends who use drugs When gaining weight Vacations/holidays When it’s raining Before a date
At lunch break While at dinner If I win money After work
Liquor store
After passing a particular street or exit
During work
School
Talking on the phone
The park
Recovery groups
In the neighborhood
After payday
Weekends
When gambling
With family members
Driving Beach
Before breakfast
At family events During work
When in pain At the casino
List usedany other activities, situations, or settings where you frequently have List activities, situations, or settings in which you would not use or gamble
List people you could be with and not use.
ERS 2A
External Trigger Questionnaire
Place a checkmark next to activities, situations, or settings in which you frequently gambled; place a zero next to activities, situations, or settings in which you never have gambled Home alone
During a date
Home with friends
Before sexual activities
Before going out to dinner
Friend’s home
After sexual activities
Before breakfast
Parties
Before work
At lunch break
Sporting events
When carrying money
While at dinner
Movies
Convenient store
After work
Bars/clubs
During work
Concerts
Talking on the phone
After passing a particular street or exit
With friends who use drugs
Recovery groups After payday
When gaining weight
At Church
Vacations/holidays When it’s raining Before a date
When buying gas When drinking or using drugs
School The park In the neighborhood Weekends With family members When in pain At the casino
When I need money Family events
List any other activities, situations, or settings where you frequently have gambled.
List activities, situations, or settings in which you would not gamble.
List people you could be with and not gamble.
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ERS 2B
External Trigger Chart
Name:
Date:
Instructions: List people, places, objects, or situations below according to their degree of association with substance use or gambling. Put an “S” next to triggers for substance use and a “G” next to triggers for gambling. Remember substance use can be a trigger for gambling and gambling can be a trigger for substance use.
0% 100% Chance of Using/Gambling Chance of Using/Gambling Never
Almost Never
Almost Always
Always
These situations
These situations
These situations
Involvement in
are “safe.”
are low risk, but
are high risk.
these situations is
caution is needed.
Staying in these
deciding to stay
situations is
addicted. Avoid
extremely
totally.
dangerous.
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ERS 3A
Internal Trigger Questionnaire
During recovery certain feelings or emotions often trigger the brain to think about using substances or Gambling. Read the following list of feelings and emotions, and place a check- mark next to those that might trigger thoughts of using or gambling for you. Place a zero next to those that are not connected with using. Afraid
Criticized
Excited
Aroused
Frustrated
Inadequate
Jealous
Revengeful
Neglected
Pressured
Bored
Worried
Angry
Depressed
Exhausted
Grieving
Guilty
Insecure
Lonely
Resentful
Nervous
Relaxed
Envious
Overwhelmed
Confident
Embarrassed
Deprived
Misunderstood
Happy
Irritated
Humiliated
Paranoid
Passionate
Sad
Anxious
Hungry
What emotional states that are not listed above have triggered you to use substances or gamble?
Was your use or gambling in the weeks before entering treatment Tied primarily to emotional conditions? Routine and automatic without much emotional triggering?
Were there times in the recent past when you were not using or gambling and a specific change in your mood clearly resulted in your wanting to use/gamble (for example, you got in a fight with someone and wanted to use in response to getting angry)? Yes ____No ___If yes, d e s c r i b e :
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ERS 3B
Internal Trigger Chart
Name:
Date:
Instructions: List emotional states below according to their degree of association with substance use and/or gambling. Put an “S” next to triggers for substance use and a “G” next to those for gambling.
0% 100% Chance of Using/Gambling Chance of Using/Gambling Never
These emotions are “safe.”
Almost Never
Almost Always
These emotions are These emotions are low risk, but caution is needed.
high risk.
Always
Persisting in these emotions is deciding to stay addicted. Avoid totally.
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ERS 4A
12-Step Introduction
Meetings What Is a 12-Step Program? In the 1930s, Alcoholics Anonymous (AA) was founded by two men who could not cope with their own alcoholism through psychiatry or medicine. They found a number of specific principles helped people overcome their alcohol dependence. They formed AA to introduce people who were dependent on alcohol to these self-help principles. The AA concepts have been adapted to stimulant and other drug addictions (for example, Crystal Meth Anonymous, Narcotics Anonymous [NA], and Cocaine Anonymous) and to addictive behaviors such as gambling and overeating. People dependent on drugs, alcohol or gambling have found that others who also are dependent can provide enormous support and help to one another. For this reason, these groups are called fellowships, where participants show concern and support for one another through sharing and understanding.
Do I Need To Attend 12-Step Meetings? If treatment in this program is going to work for you, it is essential to establish a network of support for your recovery. Attending treatment sessions without going to 12-Step meetings may produce a temporary effect. But without involvement in self-help programs, it is very unlikely that you will successfully recover. Clients in these programs should attend three 12-Step meetings per week during their treatment involvement. Many successfully abstinent people go to 90 meetings in 90 days. The more you participate in treatment and 12-Step meetings, the greater your chance for recovery.
Are All Meetings the Same? No. There are different types of meetings: Speaker meetings feature a person in recovery telling his or her story of drug,alcohol use or gambling and recovery.
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ERS 4A
12-Step Introduction
Topic meetings have a discussion on a specific topic such as fellowship, honesty, acceptance, or patience. Everyone is given a chance to talk, but no one is forced. GA meeting are most often of this format. Step/Tradition meetings are special meetings where the 12 Steps and 12 Traditions are discussed. Book study meetings focus on reading a chapter from the main text of the 12-Step group. (For AA, this is the Big Book; for NA, the Basic Text.) Book study meetings often focus on someone’s experience or a recovery-related topic. Depending on where you live, there may be language-specific meetings, gender-specific meetings, open meetings, meetings based on participants’ sexual orientation, and meetings for people who also have a mental disorder (“double trouble” Dual Recovery Anonymous meetings). GA meetings are generally closed meetings and in most areas there are fewer GA meetings and not as much variety.
Are the 12-Step Programs Religious? No. None of the 12-Step programs are religious, but spiritual growth is considered a part of recovery. Spiritual choices are very personal and individual. Each person decides for himself or herself what the term “higher power” means. Both nonreligious and religious people can find value and support in 12-Step programs.
How Do I Find a Meeting? You can call directory assistance or check the phonebook for Alcoholics Anonymous, Cocaine Anonymous, Gamblers Anonymous or Narcotics Anonymous. Listings for Crystal Meth Anonymous meetings can be found at www.crystalmeth.org. GA meetings can be found at www.gamblersanonymous.org. You can call the numbers available from the Web site and speak to someone who can tell you when and where meetings are scheduled. At meetings, directories are available that list meetings by city, street address, and meeting time and include information about the meeting (for example,
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ERS 4A
12-Step Introduction
speaker, step study, nonsmoking, men’s, or women’s). Another way to find a good meeting is to ask someone who goes to 12-Step meetings.
Sponsors The first few weeks and months of recovery are frustrating. Many things happen that are confusing and frightening. During this difficult period, there are many times when people in recovery need to talk about problems and fears. A sponsor helps guide a newcomer through this process.
What Do Sponsors Do? Sponsors help the newcomer by answering questions and explaining the 12-Step recovery process. Sponsors agree to be available to listen to their sponsorees’ difficulties and frustrations and to share their insights and solutions. Sponsors provide guidance and help address problems their sponsorees are having. This advice comes from their personal experiences with long-term abstinence. Sponsors are people with whom addiction-related secrets and guilt feelings can be shared easily. They agree to keep these secrets confidential and to protect the newcomer’s anonymity. Sponsors warn their sponsorees when they get off the path of recovery. Sponsors often are the first people to know when their sponsorees experience a slip or relapse. So, sponsors often push their sponsorees to attend more meetings or get help for problems. Sponsors help their sponsorees work through the 12 Steps.
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ERS 4A
12-Step Introduction
How Do I Pick a Sponsor? The process of choosing a sponsor is easy. The newcomer simply asks someone to be his or her sponsor. But you need to think carefully about whom you will ask to sponsor you. Most people select a sponsor who seems to be living a healthy and responsible life, the kind of life a person in recovery would want to lead. Some general guidelines for selecting a sponsor include the following: A sponsor should have several years of abstinence from all mood-altering drugs and/or gambling. A sponsor should have a healthful lifestyle and not be struggling with major problems or addiction. A sponsor should be an active and regular participant in 12-Step meetings. Also, a sponsor should be someone who actively “works” the 12 Steps. A sponsor should be someone to whom you can relate. You may not always agree with your sponsor, but you need to be able to respect your sponsor. A sponsor should be someone you would not become romantically interested in.
Alternatives to 12-Step Programs There are alternatives to 12-Step groups, many of which are not based on the concept of a higher power. Although the philosophies of these groups differ, most offer a mutual-help approach that focuses on personal responsibility, personal empowerment, and strength through an abstinent social network. Here are a few notable alternatives to 12-Step groups:
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ERS 4A
12-Step Introduction
Women for Sobriety (www.womenforsobriety.org) helps women overcome alcohol dependence through emotional and spiritual growth. Jewish Alcoholics, Chemically Dependent Persons and Significant Others (JACS) (www.jacsweb.org) helps people explore recovery in a nurturing Jewish environment. Self-Management and Recovery Training (SMART) (www.smartrecovery.org) is a cognitive–behavioral group approach that focuses on self-reliance, problemsolving, coping strategies, and a balanced lifestyle. Secular Organizations for Sobriety (www.secularhumanism.org) maintains that sobriety is a separate issue from religion or spirituality and credits the individual for achieving and maintaining sobriety. Community-based spiritual fellowships, which take place in churches, synagogues, mosques, temples, and other spiritually focused settings, often help people clarify their values and change their lives.
Questions To Consider Have you ever been to a 12-Step meeting? If so, what was your experience? Have you attended any other types of recovery meetings (such as those listed above)? Do you plan to attend any 12-Step meetings? Where? When? How might you make use of 12-Step meetings to stop using? Are there alternatives to 12-Step meetings that you might consider attending?
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ERS 4B The Serenity Prayer and the 12 Steps of Alcoholics Anonymous The Serenity Prayer God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.
The 12 Steps of Alcoholics Anonymous* 1 We admitted that we were powerless
8 Made a list of all persons we had
over alcohol—that our lives had become unmanageable.
harmed and became willing to make amends to them all.
2 Came to believe that a Power greater
9 Made direct amends to such people
than ourselves could restore us to sanity.
wherever possible, except when to do so would injure them or others.
3 Made a decision to turn our will and our lives over to the care of God as we understood Him.
4 Made a searching and fearless moral
10 Continued to take personal inventory, and when we were wrong, promptly admitted it.
inventory of ourselves.
11 Sought through prayer and medita-
5 Admitted to God, to ourselves, and to
tion to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
another human being the exact nature of our wrongs.
6 Were entirely ready to have God remove all these defects of character.
12 Having had a spiritual awakening as a result of the steps, we tried to carry this
7 Humbly asked Him to remove our
message to alcoholics and to practice
shortcomings.
these principles in all our affairs.
*The Twelve Steps are reprinted with permission of Alcoholics Anonymous World Services, Inc. (A.A.W.S.). Permission to reprint the Twelve Steps does not mean that A.A.W.S. has reviewed or approved the contents of this publication, or that A.A.W.S. necessarily agrees with the views expressed herein. A.A. is a program of recovery from alcoholism only—use of the Twelve Steps in connection with programs and activities which are patterned after A.A., but which address other problems, or in any other non-A.A. context, does not imply otherwise.
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ERS 5
Roadmap for Recovery
Recovery from a substance use disorder or problem gambling is not a mysterious process. After the use of substances or gambling is stopped, the brain goes through a biological readjustment. This readjustment process is essentially a “healing” of the chemical changes that were produced in the brain by substance use or gambling. It is important for people in the beginning stages of recovery to understand why they may experience some physical and emotional difficulties. The durations of the stages listed below are a rough guide of recovery, not a schedule. The length of stages will vary from person to person. The substance used or the nature of gambling will affect the client’s progress through the stages, too. Clients who had been using methamphetamine will tend to spend more time in each stage than clients who were using cocaine or other stimulants. Similar stages can be observed in gambling recovery, but may be more variable depending on the individual and the nature, intensity and length of gambling.
The Stages Withdrawal Stage (1 to 2 weeks) During the first days after substance use is stopped, some people experience difficult symptoms. The extent of the symptoms often is related to the amount, frequency, and type of their previous substance use. For people who use stimulants, withdrawal can be accompanied by drug craving, depression, low energy, difficulty sleeping or excessive sleep, increased appetite, and difficulty concentrating. Although people who use stimulants do not experience the same degree of physical symptoms as do people who use alcohol, the psychological symptoms of craving and depression can be quite severe. Clients may have trouble coping with stress and may be irritable.
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ERS 5
Roadmap for Recovery
People who drank alcohol in large amounts may have the most severe symptoms. The symptoms can include nausea, low energy, anxiety, shakiness, depression, intense emotions, insomnia, irritability, difficulty concentrating, and memory problems. These symptoms typically last 3 to 5 days but can last up to several weeks. Some people must be hospitalized to detox safely. For people who used opioids or prescription drugs, the 7- to 10-day withdrawal period (or longer for people who use benzodiazepines) can be physically uncomfortable and may require hospitalization and medication. It is essential to have a physician closely monitor withdrawal in people dependent on these substances. Along with the physical discomfort, many people experience nervousness, trouble sleeping, depression, and difficulty concentrating. Successfully completing withdrawal from these substances is a major achievement in early recovery. For people addicted to gambling there may or may not be a period of withdrawal. For some people withdrawal symptoms may last 1-2 weeks and can include physical as well as mental and emotional symptoms. These symptoms can include nausea, headaches, depression, agitation, confusion, anxiety, insomnia, sleeping excessively, irritability, restlessness, difficulty concentrating. The symptoms associated with gambling withdrawal are much more individualized and unpredictable than those associated with substance use disorders.
Early Abstinence (4 weeks; follows Withdrawal) For people who used stimulants, this 4-week period is called the Honeymoon. Most people feel quite good during this period and often feel “cured.” As a result, clients may want to drop out of treatment or stop attending 12-Step meetings during the Honeymoon period. Early abstinence should be used as an opportunity to establish a good foundation for recovery. If clients can direct the energy, enthusiasm, and optimism felt during this period into recovery activities, they can lay the foundation for future success.
For people who used alcohol, this 4-week period is marked by the brain’s recovery. Although the physical withdrawal symptoms have ended, clients still are getting used to the absence of substances. Thinking may be unclear, concentration may be poor, nervousness and anxiety may be troubling, sleep is often irregular, and, in many ways, life feels too intense.
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ERS 5
Roadmap for Recovery
For those who used opioids or prescription drugs, there is essentially a gradual normalization during this period. In many ways the process is similar to the alcohol recovery timetable. Slow, gradual improvement in symptoms is evidence that the recovery is progressing. Again with gambling reactions during this early abstinence can be variable. However, there is often a gradual normalization as with alcohol recovery. It often takes gamblers up to a month to begin to be able to think clearly and reason logically. There may be serious anxiety and depression as the consequences of gambling personally and financially are recognized more clearly.
Protracted Abstinence (3.5 months; follows Early Abstinence) From 6 weeks to 5 months after clients stop using, they may experience a variety of annoying and troublesome symptoms. These symptoms—difficulties with thoughts and feelings—are caused by the continuing healing process in the brain. This period is called the Wall. It is important for clients to be aware that some of the feelings during this period are the result of changes in brain chemistry. If clients remain abstinent, the feelings will pass. The most common symptoms are depression, irritability, difficulty concentrating, low energy, and a general lack of enthusiasm. Clients also may experience strong cravings during protracted abstinence. Relapse risk goes up during this period. Clients must stay focused on remaining abstinent one day at a time. Exercise helps tremendously during this period. For most clients, completing this phase in recovery is a major achievement. This may also be a high risk period for those in substance use recovery to fall into developing a behavioral addiction such as gambling without even realizing they are falling into another addictive pattern. During this period those in recovery from gambling are likely to be highly focused on coping with the consequences, particularly financial ones, of their gambling. Money problems can be a significant trigger for relapse during this phase as brain patterns that maintained gambling as a solution to financial problems are still relatively strong. Additionally, difficult emotions that had been masked by gambling may begin to arise during this period that contribute to relapse risk.
Readjustment (2 months; follows Protracted Abstinence) After 5 months, the brain has recovered substantially. Now, the client’s main task is developing a life that has fulfilling activities that support continued recovery. Although a difficult part of recovery is over, hard work is needed to improve the quality of life. Because cravings occur less often and feel less intense 6 months into recovery, clients may be less aware of relapse risk and put themselves in high-risk situations and increase their relapse risk. For recovering gamblers, a high risk period for gambling may not occur until a year or more into recovery. Once financial consequences appear under control or are reduced, recovering gamblers often experience a sense of complacency that leads to a return to gambling. Often gamblers during this period of recovery have been primarily focused on simply not gambling. Once a significant period of abstinence has been achieved, other issues such as relationship problems, employment issues, etc may become more apparent and contribute to relapse risk. Therefore, learning how to cope with these life issues in a recovery oriented way is key to this period of recovery as is learning how to enjoy life in recovery.
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ERS 6A
Five Common Challenges in Early Recovery
Everyone who attempts to stop using substances or stop gambling runs into situations that make it difficult to maintain abstinence. Listed below are five of the most common situations that are encountered during the first few weeks of treatment. Next to these problems are some suggested alternatives for handling these situations.
Challenges Friends and associates who use or gamble: You want to continue associations with old friends or friends who use or gamble
Anger, irritability:
New Approaches Try to make new friends at 12-Step or mutual-help meetings. Participate in new activities or hobbies that will increase your chances of meeting abstinent people. Plan activities with abstinent friends or family members.
Remind yourself that recovery involves a healing of brain chemistry. Strong, unpredictable emotions are
Small events can cre-
a natural part of recovery.
ate feelings of anger
Engage in exercise.
that seem to preoccupy your thoughts and
Talk to a counselor or a supportive friend.
can lead to relapse.
Substances or gambling in the home: You have decided to stop using/gambling, but others in your house may still be use/gamble.
Get rid of all drugs, alcohol or gambling paraphernalia (cards, preferred player cards, etc) Ask others to refrain from using,drinking or gambling at home. If you continue to have a problem, think about moving out for a while.
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ERS 6A
Five Common Challenges in Early Recovery
Challenges Boredom, loneliness: Stopping substance use or gambling often means that activities you did for fun and the people with
New Approaches Put new activities in your schedule. Go back to activities you enjoyed before your addiction took over. Develop new friends at 12-Step or mutual-help meetings.
whom you did them must be avoided.
Special occasions:
Have a plan for answering questions about not
Parties, dinners, business
using substances or gambling.
meetings, and holidays
Start your own abstinent celebrations and traditions.
without substance use/gambling can be difficult.
Have your own transportation to and from events. Leave if you get uncomfortable or start feeling deprived.
Are some of these issues likely to be problems for you in the next few weeks? Which ones?
How will you handle them?
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ERS 6B
Alcohol/Gambling Arguments
Have you been able to stop using alcohol completely or have you never considered gambling to be a problem? At about 6 weeks into the recovery process, many people return to alcohol use. Has your addicted brain played with the idea? Have you been gambling more as a way to fill up time or spend money you used to use on drugs or alcohol? These are some of the most common arguments against stopping the use of alcohol or looking to gambling to fill in empty spaces and answers to the arguments.
I came here to stop using speed, not to stop drinking or worry about my gambling. Part of stopping methamphetamine use is stopping all substance use, including alcohol use and becoming aware of behaviors like gambling that can become a sequential addiction or a serious relapse risk factor.
I’ve had drinks and gambled and not used, so it doesn’t make any difference. Drinking and gambling over time greatly increase the risk of relapse. A single drink or bet does not necessarily cause relapse anymore than a single cigarette causes lung cancer. However, with continued drinking or gambling, the risks of relapse greatly increase. Additionally drinking and gambling can develop into their own addictions.
Drinking and/or gambling actually help. When I have a craving, a drink or going gambling calms me down, and the craving goes away. Alcohol and gambling interfere with the brain’s chemical healing process. Continued alcohol use eventually intensifies cravings, even if one drink seems to reduce cravings. Gambling keeps addictive brain pathways working and prevents the learning of recovery oriented coping skills.
I’m not an alcoholic or a compulsive gambler, so why do I need to stop drinking or worry about my gambling. If you’re not an alcoholic, you should have no problem stopping alcohol use. If you can’t stop, maybe alcohol is more of a problem than you realize. Additionally, if you aren’t willing to look at impact of gambling on your substance use, maybe you are at high risk for gambling becoming your next addition. If you aren’t a compulsive gambler, you shouldn’t have trouble stopping or limiting your gambling.
I’m never going to use drugs again, but I’m not sure I’ll never drink again. Also, I’ m not sure I want to stop or limit my gambling. Make a 6-month commitment to total abstinence. Give yourself the chance to make a decision about alcohol and gambling with a drug-free brain. If you reject alcohol or gambling abstinence because “forever” scares you, then you’re justifying drinking and/or gambling now and risking relapse to substance use.
Has your addicted brain presented you with other justifications? If so, what are they?
How are you planning to handle alcohol and/or gambling use in the future?
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ERS 7A
Thoughts, Emotions, and Behavior
Habitual substance use and/or gambling changes the way people think, how they feel, and how they behave. How do these changes affect the recovery process?
Thoughts Thoughts happen in the rational part of the brain. They are like pictures on the TV screen of the mind. Thoughts can be controlled. As you become aware of your thoughts, you can learn to change channels in your brain. Learning to turn off thoughts of substance use and/or gambling is a very important part of the recovery process. It is not easy to become aware of your thinking and to learn to control the process. With practice it gets easier.
Emotions Emotions are feelings. Happiness, sadness, anger, and fear are some basic emotions. Feelings are the mind’s response to things that happen to you. Feelings cannot be controlled; they are neither good nor bad. It is important to be aware of your feelings. Talking to family members, friends, or a counselor can help you recognize how you feel. People normally feel a range of emotions. Drugs and gambling can change your emotions by changing the way your brain works. During recovery, emotions are often still mixed up. Sometimes you feel irritated for no reason or great even though nothing wonderful has happened. You cannot control or choose your feelings, but you can control what you do about them.
Behavior What you do is behavior. Work is behavior. Play is behavior. Going to treatment is behavior, substance use and gambling are behaviors. Behavior can result from an emotion, from a thought, or from a combination of both. Repeated use of a substance or repeated gambling changes your thoughts and pushes your emotions toward substance use and/or gambling. This powerful, automatic process has to be brought
back under control for recovery to occur. Structuring time, attending 12-Step or mutual-help meetings, and engaging in new activities are all ways of regaining control. The goal in recovery is to learn to combine your thinking and feeling self and behave in ways that are best for you and your life.
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ERS 7B
Addictive Behavior
People who abuse substances or gamble excessively often feel that their lives are out of control. Maintaining control becomes harder and harder the longer they have been abusing substances or gambling problematically. People do desperate things to continue to appear normal. These desperate behaviors are called addictive behaviors—behaviors related to substance use and gambling. Sometimes these addictive behaviors occur only when people are using/gambling or moving toward using or gambling. Recognize when you begin to engage in these behaviors. That’s when you know to start fighting extra hard to move away from relapse.
Which of these behaviors do you think are related to your drug or alcohol use or gambling? Lying Stealing
Behaving compulsively (for example, too much eating, working, sex)
Being irresponsible (for example, not meeting family or work commitments)
Changing work habits (for example, working more, less, not at all, new job, change in hours)
Being unreliable (for example, being late for appointments, breaking promises)
Losing interest in things (for example, recreational activities, family life)
Being careless about health and grooming (for example, wearing “using” clothes, avoiding exercise, eating poorly, having a messy appearance)
Isolating (staying by yourself much of the time)
Getting sloppy in housekeeping
Using other drugs, alcohol or gambling
Behaving impulsively (without thinking)
Missing or being late for treatment
Stopping prescribed medication (for example, disulfiram, naltrexone)
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ERS 8
12-Step Sayings
The program of Alcoholics Anonymous and other 12 step programs have developed some short sayings that help people in their day-to-day efforts at staying sober. These concepts are often useful tools in learning how to establish sobriety.
One day at a time. This is a key concept in staying abstinent. Don’t obsess about staying abstinent forever. Just focus on today.
Turn it over. Sometimes people with addictions jeopardize their recovery by tackling problems that cannot be solved. Finding a way to let go of issues so that you can focus on staying abstinent is a very important skill.
Keep it simple. Learning to stay abstinent can get complicated and seem overwhelming if you let it. In fact, there are some simple concepts involved. Don’t make this process difficult: keep it simple.
Take what you need and leave the rest. Not everyone benefits from every part of 12-Step meetings. It is not a perfect program. However, if you focus on the parts you find useful, rather than the ones that bother you, the program has something for you.
Bring your body, the mind will follow. The most important aspect of 12-Step programs is attending the meetings. It takes a while to feel completely comfortable. Try different meetings, try to meet people, and read the materials. Just go and keep going.
HALT This acronym is familiar to people in the 12-Step programs. It is a shorthand way of reminding people in recovery that they are especially vulnerable to relapse when they are too hungry, angry, lonely, or tired.
Hungry: When people are using or gambling, they often ignore their nutritional needs. People in recovery need to relearn the importance of eating regularly. Being hungry can cause changes in body chemistry that make people less able to control themselves or avoid cravings. Often the person feels anxious and upset but doesn’t associate the feelings with hunger. Eating regularly increases emotional stability.
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ERS 8
12-Step Sayings
Angry: This emotional state is probably the most common cause of relapse to drug use or gambling. Learning to cope with anger in a healthy way is difficult for many people. It is not healthy to act in anger without thinking about the consequences. Nor is it healthy to hold anger in and try to pretend it doesn’t exist. Talking about anger-producing situations and how to handle them is an important part of recovery.
Lonely: Recovery is often a lonely process. People lose relationships because of their substance use and gambling. As part of staying abstinent, people in recovery may have to give up friends who still use or gamble. The feelings of loneliness are real and painful. They make people more vulnerable to relapse.
Tired: Sleep disorders are often a part of early recovery. People in recovery frequently have to give up chemical aids to sleep that they used in the past. Also, the worries and anxiety associated with facing the negative consequences of addiction can contribute to sleep disturbance. Being tired is often a trigger for relapse. Feeling exhausted and low on energy leaves people vulnerable and unable to function in a healthy way.
How often do you find yourself in one or more of these emotional states?
What could you do differently to avoid being so vulnerable?
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RP 1
Alcohol
It is often difficult for people to stop drinking when they enter treatment. Some reasons for this follow. Triggers for alcohol use are everywhere. It is sometimes hard to do anything social without facing people who are drinking. How can you get together with your
friends without drinking?
Many people use alcohol in response to internal triggers. Depression and anxiety seem to go away when they have a drink. It’s difficult for people to realize that sometimes the alcohol causes the depression. What moods and feelings make
you want to have a drink?
If a person is dependent on an illicit drug and uses alcohol less often, alcohol may not be viewed as a problem until the person tries to stop drinking. What challenges have
you faced in stopping drinking since you entered treatment?
Alcohol affects the rational, thinking part of the brain. It is difficult to think reasonably about a substance that makes thinking clearly more difficult. How does it feel to be
sober at a party and watch people drink and act stupidly?
Alcohol dulls the rational brain. Alcohol lowers people’s inhibitions and can make people more sexually aggressive, less self-conscious, and more sociable. People who use alcohol to decrease inhibitions and help them socialize may feel uncomfortable without it.
In what ways have you depended on alcohol? For sexual or social reasons?
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RP 1
Alcohol
Many of us grow up using alcohol to mark special occasions. It is hard to learn how to celebrate those times without drinking. What special
occasions did your family celebrate with alcohol?
How do you celebrate now?
In many families and social groups, drinking is a sign of strength or maturity. Drinking often is seen as a way of being “one of the gang.” Do you feel less “with it” when
you are not drinking? If so, in what ways?
Drinking can become linked to certain activities. It can seem difficult during early recovery to do those things without a beer or other drink (for example, eating certain kinds of foods, going to sporting events). What activities seem to go with drinking
for you?
It is important to remember that everyone who stops drinking has these problems at first. As you work through the difficult situations and spend more time sober, it does get easier.
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RP 1
Gambling
Generally people do not think about the impact of gambling on their recovery when they stop using substances. Some reasons for this follow. Gambling is a very normalized behavior in our society. The majority of adults gamble and it is readily available just about everywhere, from stores that sell lottery tickets, to sports betting, card games, dice, casinos. Gambling can be found in the workplace, at sporting events. You hear about it on the news. What can you do for fun and entertainment that does not involve gambling? Just as with alcohol, many people use gambling in response to internal triggers. Depression and anxiety seem to go away when they gamble. It’s difficult for people to realize that sometimes the gambling makes the depression and anxiety worse.
What moods and feelings make you want to gamble?
If a person is dependent on an illicit drug and gambles less often, gambling may not be viewed as a problem until the person stops the drug use. At that point, the person may find themselves gambling as a replacement for their drug use or using money previously spent on drugs for gambling. Have you been spending more time and money on gambling than previously?
Gambling can often create the same feelings that drug use did. In what ways are feelings you experience while gambling the same as feelings you had when using? Gambling often creates an environment where people feel more socially accepted or can be around people with less anxiety. In what ways does gambling help you feel less socially anxious or feel a sense of belonging in social setting?
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RP 1
Gambling
Many of us grow up gambling to mark special occasions. It is hard to learn how to celebrate those times without gambling. How was
gambling a part of special occasions in your family?
How do you celebrate now?
In many families and social groups, gambling is a sign of cleverness or maturity. Gambling often is seen as a way of being “one of the gang.” How does gambling make you feel smart or “cool”.
Gambling can become linked to certain activities. It can seem difficult during early recovery to do those things without betting (for example, going to or watching sporting events, just going to the grocery store or buying gas, going to a concert). What
activities seem to go with gambling for you?
As you look at gambling in these ways, how do you see gambling as either supporting or putting your recovery at risk?
RP 2
Boredom
Often people who stop using drugs or gambling say life feels boring. Some reasons for this feeling include the following: A structured, routine life feels different from a lifestyle built around substance use or gambling. Brain chemical changes during recovery can make people feel listless (or bored). People who use substances or gamble often have huge emotional swings (high to low and back to high). Normal emotions can feel flat by comparison. People who have been abstinent a long time rarely complain of continual boredom. The problem of boredom in recovery does improve. Meanwhile you should try some different activities to help remedy the problem of boredom in recovery. However be cautious that you do not trade one addictive behavior for another. Gambling may not be the safest activity as an alternative to substance use.
List five recreational activities you want to pursue. 1. 2. 3. 4. 5.
Have you started doing things that you enjoyed before using drugs or gambling? Have you begun new activities that interest you? What are they?
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RP 2
Boredom
Can you plan something to look forward to? What will you plan?
How long has it been since you’ve taken a vacation? A vacation doesn’t have to involve travel—just time away from your regular routine. What kind of break will you plan for yourself?
Here are some tips to reduce feelings of boredom: Recognize that a structured, routine life feels different from a lifestyle built around substance use or gambling. Make sure you are scheduling activities. Forcing yourself to write down daily activities helps you fit in more interesting experiences. Try not to become complacent in recovery. Do something that will further your growth. Sometimes boredom results from not challenging yourself enough in your daily living. Which of the suggestions listed above might work for you? It is important to try new ways of fighting boredom. Boredom can be a trigger that moves you toward relapse.
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RP 3A
Avoiding Relapse Drift
How Relapse Happens Relapse does not happen without warning, and it does not happen quickly. The gradual movement from abstinence to relapse can be subtle and easily explained away or denied. So a relapse often feels as if it happens suddenly. This slow movement away from abstinence can be compared to a ship gradually drifting away from where it was moored. The drifting movement can be so slow that you don’t even notice it.
Interrupting Relapse Drift During recovery people do specific things that keep them abstinent. These activities can be called “mooring lines.” People need to understand what they are doing to keep themselves abstinent. They need to list these mooring lines in a specific way so they are clear and measurable. These activities are the “ropes” that hold recovery in place and prevent relapse drift from happening without being noticed.
Maintaining Recovery Use the Mooring Lines Recovery Chart (RP 3B) to list and track the things that are holding your recovery in place. Follow these guidelines when filling out the form: Identify four or five specific things that now are helping you stay abstinent (for example, working out for 20 minutes, 3 times a week). Include items such as exercise, therapist and group appointments, scheduling activities, 12-Step meetings, eating patterns. Do not list attitudes. They are not as easy to measure as behaviors. Note specific people or places that are known triggers and need to be avoided during recovery.
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RP 3A
Avoiding Relapse Drift
You should complete your Mooring Lines Recovery Chart weekly. Place a checkmark next to each mooring line that you know is secure and record the date. When two or more items cannot be checked, it means that relapse drift is happening. Sometimes events interfere with your mooring lines. Emergencies and illnesses cannot be controlled. The mooring lines disappear. Many people relapse during these times. Use the chart to recognize when you are more likely to relapse, and decide what to do to keep this from happening. (After 5 weeks when the chart is full, transfer the list of mooring lines to a journal or pages 12 and 13 of your Client’s Treatment Companion, and continue to check your mooring lines.)
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RP 3B
Mooring Lines Recovery Chart
You have learned new behaviors that keep you in recovery. These behaviors are the mooring lines that keep your recovery steady and in place. It is important to chart the new behaviors and check every week to make sure the lines are secure. Dropping one or more of the mooring lines allows you to drift toward relapse. Use the chart below to list activities that are important to your continuing recovery. If there are specific people or things you need to avoid, list those. Check your list each week to make sure you are continuing to stay anchored in your recovery.
Mooring Line Behaviors
Date
Date
Date
Date
Date
I Am Avoiding
Date
Date
Date
Date
Date
45
RP 4
Work and Recovery ertain employment situations can C make treatment and recovery more difficult. Some difficult situations are outlined below.
Employed in a Demanding Job That Makes Treatment Difficult Your treatment won’t work unless you give it 100 percent of your effort. People in recovery need to find a way to balance work with treatment so they can give recovery their full effort. Some jobs require long or unusual hours. Often the very nature of the work schedule has contributed to the substance use or gambling problem. The first task, if you have such a job, is to adjust your schedule to accommodate treatment. Work with your counselor and your boss or representative from your employee assis- tance program to do this. You also should find out whether flextime is an option. Recovery needs to be the first priority while you are in treatment.
Working in an Unsatisfactory Job; Thinking of Making a Change During recovery major changes (in jobs, in relationships, etc.) should be delayed for 6 months to 1 year whenever possible. Reasons for this include the following: People in recovery go through big changes. Sometimes they change their views on personal situations. Any change is stressful. Major stress should be avoided as much as possible during recovery.
Working in a Situation Where Recovery Will Be Difficult Some jobs lend themselves to recovery more than others. Work situations that are difficult to combine with outpatient treatment include
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RP 4
Work and Recovery
Situations where it is necessary to be with other people who are drinking, using or gambling Jobs in which large sums of cash are available at unpredictable times People in these types of jobs may want to plan for a job change.
Unemployed and Needing To Find a Job When people are out of work, treatment becomes more difficult for the following reasons: Looking for work is often the first priority. Abundant free time is difficult to fill, and the structure that makes outpatient treatment effective is lacking. Resources often are more limited, making transportation and child care more of a problem. If you are out of work and in treatment, remember that recovery still needs to be your first priority. Make sure the counselor knows your situation, and strive to balance job-seeking activities and treatment. There are no easy solutions to these problems. It is important to be aware of the issues so that you can plan to make your recovery as strong as possible.
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47
RP 5
Guilt and Shame
Guilt is feeling bad about what you’ve done: “I am sorry I spent so much time using drugs and/or gambling and not paying attention to my family.”
What are some things you have done in the past that you feel guilty about?
Feeling guilty can be a healthy reaction. It often means you have done something that doesn’t agree with your values and morals. It is not unusual for people to do things they feel guilty about. You can’t change the past. It is important to make peace with yourself. Sometimes that means making amends for things you’ve said and done. Remember the following: It’s all right to make mistakes. It’s all right to say, “I don’t know,” “I don’t care,” or “I don’t understand.” You don’t have to explain yourself to anyone if you’re acting responsibly.
Do you still feel guilty about the things you listed? What can you do to improve the situation?
Shame is feeling bad about who you are: “I am hopeless and worthless.”
Do you feel ashamed of being dependent on substances and/or gambling? Yes ____ No _____
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RP 5
Guilt and Shame
Do you feel you are weak because you couldn’t or can’t stop using or gambling? Yes
No
Do you feel you are stupid because of what you have done? Yes
No
Do you feel that you are a bad person because you are involved with substance use or excessive gambling? Yes ____No ____ Recovery is always a hard process. No one knows why some people can stop using substances or gambling excessively once they enter treatment and decide to be abstinent and other people struggle to maintain abstinence. Research shows that family histories, genes, and individual physical differences in people play a role. Being dependent on drugs or alcohol does not mean you are bad, stupid, or weak. What we do know is that you cannot recover by Trying to use willpower
Trying to be good
Trying to be strong Two things to make recovery work are Being smart
Working hard
Everyone who is successful at recovery will tell you, “It was the hardest thing I ever did.” No one can do it for you, and it will not happen to you.
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49
RP 6
Staying Busy
Learning to schedule activities and structure your recovery is important in outpatient treatment. Staying busy is important for several reasons. Often relapses begin in the head of a person who has nothing to do and nowhere to go. The addicted brain begins to think about past using and/or gambling, and the thoughts can start the craving process. How has free time been a trigger for you?
How could you respond to prevent relapse if free time led to thoughts of using and/or gambling?
Often people who abuse substances or gamble compulsively begin to isolate themselves. Being around people is uncomfortable and annoying. Being alone results in fewer hassles. Did you isolate yourself when you used? If so, how did this
isolation affect your substance abuse or gambling?
How does being alone now remind you of that experience?
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RP 6
Staying Busy Being involved with people and doing things keeps life interesting. Living a substance/gambling-free life can sometimes feel pretty tame. You begin to think being abstinent is boring and using is exciting and desirable. People have to work at finding ways to make abstinence fun. What have you done
lately to have fun?
When people’s lives become consumed with substance use and/or gambling, many things they used to do and people they used to do them with get left behind. Beginning to reconnect or to build a life around substance-free and non-gambling activities and people is critical to a successful recovery. How have you reconnected with old activities
and friends? How have you built new activities and brought new people into your life?
If you have not reconnected with old activities and friends or added some new activities and people to your life, what are your plans to do so?
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51
RP 7
Motivation for Recovery
Ask any group of people who are new to recovery why they want to stop using and/or gambling right now and you will get many different answers: I was arrested, and it’s either this or jail. My wife says if I don’t stop, we are finished. Last time I used/gambled I thought I was going to die; I know I’ll die if I use/gamble again. Last time I gambled I was so ashamed at how much I lost, I wanted to kill myself. I don’t ever want to feel that way again. They are going to take the children from us unless we stop. I’ve been using/gambling for 20 years now; it’s time to change. I’m tired of being broke all the time.
Which of the people quoted is most likely to be successful in recovery? It seems logical to think that people who want to stop using for themselves and not because someone else wants them to are more likely to do well in treatment. However, that may not be true. Research shows that the reasons people stop using or gambling don’t predict whether they will be able to lead substance/gambling-free lives. What does make a difference is whether they can stay substance/gambling free long enough to appreciate the benefits of a different lifestyle. When debts are not overwhelming, relationships are rewarding, work is going well, and health is good, the person in recovery wants to stay abstinent.
FEAR WILL GET PEOPLE INTO TREATMENT, BUT FEAR ALONE IS NOT ENOUGH TO KEEP THEM IN RECOVERY.
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RP 7
Motivation for Recovery
List some of your reasons for entering treatment (for example, medical problems, family pressure, job problems, depression, financial problems).
List some of your reasons for continuing to work on your recovery today.
Do you feel that your reasons for initially stopping substance use or gambling are the same as your reasons for staying abstinent today? Why or why not?
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53
RP 8
Truthfulness
During Substance Dependence or Problem Gambling Not being truthful is part of substance dependence and problem gambling. It is hard to meet the demands of daily living (relationships, families, jobs) and use substances or gamble excessively regularly. As you become more dependent on the substance or gambling, the activities that are necessary to obtain, use, and recover from the substance/gambling take up more of your life. It becomes more and more difficult to keep your life on track. People who are substance dependent or gamble compulsively often find themselves doing and saying whatever is necessary to avoid problems. Telling the truth is not important to them.
In what ways were you less than truthful when you were using substances/gambling?
During Recovery Being honest with yourself and with others during the recovery process is critically important. Sometimes being truthful is very difficult for the following reasons: You may not seem to be a nice person. Your counselor or group members may be unhappy with your behavior. You may be embarrassed. Other people’s feelings may be hurt.
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RP 8
Truthfulness
Being in treatment without being truthful may make everything you are doing a waste of time.
How has truthfulness been difficult for you in recovery?
Being partly honest is not being truthful. Do you ever
Decide to let someone believe a partial truth?
Yes
No
Tell people what they want to hear?
Yes
No
Tell people what you wish were true?
Yes
No
Tell less than the whole truth?
Yes
No
ATTENDING GROUPS, ATTENDING MEETINGS, GOING TO A HOSPITAL, AND GOING TO A COUNSELOR ARE WASTES OF TIME AND MONEY WITHOUT TRUTHFULNESS.
RECOVERY FROM ADDICTION IS IMPOSSIBLE WITHOUT TRUTHFULNESS.
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RP 9
Total Abstinence
Have you ever found yourself saying any of the following? My problem is my meth use. Alcohol, marijuana or gambling aren’t a problem for me. Having a beer or glass of wine is not really drinking. Just buying lottery tickets can’t be a gambling problem. I drink only when I choose to. My drinking is not out of control. Gambling isn’t a problem, I can make money. I don’t really care about alcohol. I drink only to be sociable. Isn’t it better if I spend my money gambling than buying drugs? If you entered the program to stop using stimulants, you may have wondered why you were asked to sign an agreement stating your willingness also to stop using other substances, including alcohol and look at gambling behaviors. For many reasons, total abstinence is a necessary goal along with considering other addictive behaviors for people in recovery Followup studies show that people who use stimulants are eight times more likely to relapse if they use alcohol and three times more likely to relapse if they use marijuana than people who do not use these substances. You can reduce your chances of relapsing greatly by maintaining total abstinence. Studies show that people in treatment for substance use who gambling even moderately are likely to have more detox admissions, more psychiatric hospitalizations, be more depressed and have more legal problems. Places and people associated with drinking and gambling often are the very places and people who are triggers for substance use. When you’re learning to handle problems without taking stimulants,
using another drug, alcohol or gambling to numb the uncomfortable learning process is harmful for two reasons. First, such use/behavior prevents you from directly confronting your stimulant use problem. Second, it puts you at risk of becoming dependent on alcohol, another substance or gambling while you try to overcome your dependence on stimulants. Remember, if it’s more difficult to stop drinking or control your gambling than you expected, maybe you are more dependent on alcohol or gambling than you think.
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RP 10
Sex and Recovery
Intimate Sex Intimate sex involves a significant other. The sex is a part of the relationship. Sometimes the sexual feelings are warm and mellow. Sometimes they are wild and passionate. But they result from and add to the feelings each partner has for the other.
Impulsive Sex In this definition of impulsive sex, the partner is usually irrelevant; the person is a vehicle for the high. Impulsive sex can take the form of excessive masturbation. Impulsive sex can be used and abused in the same way drugs are used and abused. It is possible to become addicted to impulsive sex.
What kind of experiences have you had with impulsive sex?
Is impulsive sex linked to your drug use or gambling? How?
Describe a healthy, intimate sexual relationship that you have had or hope to have.
Impulsive sex is not part of a healthy recovery lifestyle. It can be the first step in the relapse process. Like using alcohol, drugs other than stimulants, or gambling, engaging in impulsive sex can trigger a relapse and result in use of stimulants.
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RP 11
Anticipating and Preventing Relapse
Why Is Relapse Prevention Important? Recovery is more than not using drugs, alcohol or gambling. The first step in treatment is stopping drug, alcohol use or gambling. The next step is not starting again. This is very important. The process for doing it is called relapse prevention.
What Is Relapse? Relapse is going back to substance use and to all the behaviors and patterns that come with it. Often the behaviors and patterns return before the substance use or gambling. Learning to recognize the beginning of a relapse can help people in recovery stop the process before they start using/gambling again.
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RP 11
Anticipating and Preventing Relapse
What Are Addictive Behaviors? The things people do as part of abusing drugs, alcohol or gambling are called addictive behaviors. Often these are things that addicted people do to get drugs or alcohol, to continue gambling, to cover up substance abuse/gambling, or as part of abusing. Lying, stealing, being unreliable, and acting compulsively are types of addictive behaviors. When these behaviors reappear, people in recovery should be alerted that relapse will soon follow if they do not intervene.
What are your addictive behaviors?
What Is Addictive Thinking? Addictive thinking means having thoughts that make substance use or compulsive gambling seem OK. (In 12-Step programs this is known as “stinking thinking.”) Some examples follow: I can handle just one drink/bet. This time my luck will change If they think I’m using/gambling, I might as well. I have worked hard. I need a break.
How have you tried to find excuses to use substances or gamble?
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RP 11
Anticipating and Preventing Relapse
What Is Emotional Buildup? Feelings that don’t seem to go away and just keep getting stronger cause emotional buildup. Sometimes the feelings seem unbearable. Some feelings that can build are boredom, anxiety, sexual frustration, irritability, and depression.
Have you experienced a buildup of any of these emotions?
The important step is to take action as soon as you recognize the danger signs.
Which actions might help you prevent relapse? Calling a counselor
Exercising
Calling a friend
Talking to your spouse
Taking a day off
Scheduling time more rigorously
Talking to your family
Other:
Going to a 12-Step or outside mutual-help support meeting
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RP 12
Trust
How has substance use or gambling affected the trust between you and people you care about?
If you tell someone you’re not using/gambling and the person doesn’t believe you, does it make you feel like using/gambling? Do you think, “If people are going to treat me as if I’m using/gambling, I might as well”?
People who are substance dependent or gamble too much find it difficult to have open, honest relationships. Things are said and done that destroy trust and damage relationships. Substance abuse/gambling becomes as important as or more important than other people. When substance abuse/gambling stops, the trust does not return right away. To trust means to feel certain you can rely on someone. People cannot be certain just because they want to be. Trust can be lost in an instant, but it can be rebuilt only over time. Trust will return gradually as the person who violated the trust gives another person reasons to trust again. One or both people may want the trust to return sooner, but it takes time for feelings to change.
How do you cope with suspicions about drug use or gambling?
What can you do to help the process of reestablishing trust?
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RP 13
Be Smart, Not Strong
“I can be around drugs ,alcohol or gambling. I’m sure I don’t want to use or gamble, and once I make up my mind, I’m very strong.” “I have been doing well, and I think it’s time to test myself to see whether I can be around friends who are using/gambling. It’s just a matter of willpower.” “I can have a drink or gamble and not use. I never had a problem with alcohol or gambling anyway.” Staying abstinent has little to do with how strong you are. People who maintain abstinence do it by being smart. They know that the key to not drinking, gambling and not using is to keep far away from situations in which they might use. If you are in an environment where drugs might appear (for example, at a club or party) or with friends who are drinking, gambling and using, your chances of using are much greater than if you weren’t in that situation. Smart people stay abstinent by avoiding triggers and relapse situations.
DON’T COUNT ON BEING STRONG. BE SMART. How smart are you being? Rate how well you are doing in avoiding relapse. (Circle the appropriate number.) Poor
Fair
Good Excellent
1. Practicing thought stopping
1
2
3
4
2. Scheduling
1
2
3
4
3. Keeping appointments
1
2
3
4
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RP 13
Be Smart, Not Strong Poor
Fair
Good Excellent
4. Avoiding triggers
1
2
3
4
5. Not using alcohol
1
2
3
4
6. Not using drugs
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
11. Being truthful
1
2
3
4
12. Going to 12-Step or mutual-help meetings
1
2
3
4
7. Not gambling 8. Avoiding people who use drugs, alcohol or gamble 9. Avoiding places where you might encounter drugs, alcohol or gambling 10 Exercising
Add up the circled numbers. The higher your total, the better your Recovery IQ. The best possible Recovery IQ is 44. I scored
.
This is your Recovery IQ. What can you do to improve your Recovery IQ?
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RP 14
Defining Spirituality
Look at these definitions of spirituality. Which ones describe what spirituality means to you? Spirituality is 1. A person’s relationship with God 2. The deepest level from which a human being operates 3. The philosophical context of a person’s life (values, rules, attitudes, and views) 4. The same as religion 5. Other: The second and third definitions describe spirituality in a broad sense. When it comes to recovery, these broad definitions are the most useful way to think of spirituality. They describe being spiritual as having to do with a person’s spirit or soul, as distinguished from his or her physical being. Some people believe the level and degree of spirituality in a person’s life help determine the quality of life. One way to assess the quality of your spirituality is by answering the following questions:
What do you want from life? Are you getting it?
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RP 14
Defining Spirituality
On what is your spiritual security based? (What would it take to destroy your sense of self-worth?)
Who do you have to be before you approve of yourself? (What qualities are most important to you?)
What does success mean to you? (What does “making it” mean?)
To live an abstinent life, the person in recovery has to be comfortable within himself or herself. Gaining a sense of spirituality gives many people the inner peace that makes abusing substances or gambling excessively unnecessary. Twelve-Step and mutual- help programs provide one way to gain or regain a love of oneself and of life.
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RP 15
Managing Life; Managing Money
Managing Life Maintaining a substance-dependent or problem gambling lifestyle takes a lot of time and energy. People who are substance dependent or gamble problematically give little time or thought to everyday responsibilities. When recovery begins, long-neglected responsibilities come flooding back. It sometimes is overwhelming to think about all the things that need to be done. It also is frustrating and time consuming to catch up on so many responsibilities. Determine how well you are managing your life by answering the following questions:
Do you have outstanding traffic tickets? Have you filed all your tax returns to date? Are there unpaid bills you need to make arrangements to pay? What repair and maintenance does your house or apartment need?
Does your car need to be serviced or repaired? Do you have adequate insurance? Do you have a checking account or a way to manage your finances? Are you handling daily living chores (for example, buying groceries, doing laundry, cleaning)? If you try to do all this at once, you may feel overwhelmed and hopeless. Take one item each week and focus on clearing up one area at a time. Handling these issues will help you regain control over your life.
The first item I need to take care of is: I will start by: The second item I need to take care of is: I will start by:
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RP 15
Managing Life; Managing Money
Managing Money Being in control of your finances is being in control of your life. When people who are substance dependent are using, or when gambling too much, the out-of-control lifestyle often affects their finances.
How many of the following have been true for you? Any amount of money over drugs/gamble.
is a trigger to buy
I have concealed money to buy drugs/gamble. I have large debts. I gamble with my money. I spend compulsively when I feel bad. I frequently argue about money with family members. I have stolen to get money to buy substances or gamble. When they first enter treatment, some clients choose to give control of their money to someone they trust. If you make that decision, you are controlling your finances and asking the trusted person to act as your banker. Together with your counselor, you should decide when you can handle money again safely. Then you can begin working toward financial maturity. You may choose to have some of the following goals: Arrange to pay off large debts in small, regular payments.
Use bank accounts to help you manage your money.
Budget your money carefully, as you schedule your time.
Live within your means.
Arrange spending agreements with anyone who shares your finances.
What are your other financial goals?
Make a savings plan.
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RP 16
Relapse Justification I
Once a person decides not to use drugs or gamble anymore, how does he or she end up using or gambling again? Do relapses happen completely by accident? Or are there warning signs and ways to avoid relapse? Relapse justification is a process that happens in people’s minds. A person may have decided to stop using/gambling, but the person’s brain is still healing and still feels the need for the substances or gambling. The addicted brain invents excuses that allow the person in recovery to edge close enough to relapse situations that accidents can happen. You may remember a time when you intended to stay substance/gambling free but you invented a justification for using or gambling. Then, before you knew it, you had used or gambled again. Use the questions below to help you identify justifications invented by your addicted brain. Identifying and anticipating the justifications will help you interrupt the process.
Someone Else’s Fault Does your addicted brain ever convince you that you have no choice but to use or gamble? Does an unexpected situation catch you off guard? Have you ever
said any of the following to yourself?
An old friend called, and we decided to get together and go to the casino. I had friends come for dinner, and they brought me some wine. I was in a bar, and someone offered me a beer.
Other:
Catastrophic Events Is there one unlikely, major event that is the only reason you would use or gamble? What might such an event be for you?
My spouse left me. There’s no reason to stay clean. I just got injured. It’s ruined all of my plans. I might as well use/gamble. I lost my job, I might as well use/gamble.
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RP 16
Relapse Justification I
There was a death in the family. I can’t get through this without using/gambling. Other:
For a Specific Purpose Has your addicted brain ever suggested that using drugs, alcohol or gambling is the only way to accomplish something? I’m gaining weight and need stimulants to control my weight. I’m out of energy. I’ll function better if I use. I can’t pay my bills if I don’t gamble. I need drugs to meet people more easily. I can’t enjoy sex without using. Other:
Depression, Anger, Loneliness, and Fear Does feeling depressed, angry, lonely, or afraid make using seem like the answer? I’m depressed. What difference does it make whether I use or gamble? When I get mad enough, I can’t control what I do. I’m scared. I know if I use, the feeling will go away. If my partner thinks I’ve used or gambled, I might as well. I’m so sad and lonely, gambling is the only thing that makes me feel better. Other:
What might you do when your addicted brain suggests these excuses to use?
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RP 17
Taking Care of Yourself
People who are substance or gambling dependent often do not take care of themselves. They don’t have the time or energy to pay attention to health and grooming. Health and personal appearance become less important than substance use or gambling. Not caring for oneself is a major factor in losing selfesteem. To esteem something means to see value in it, to acknowledge its importance. People in recovery need to recognize their own value. In recovery, your own health and appearance become more important as you care more for yourself. Taking care of yourself is part of starting to like and respect yourself again. Paying attention to the following concerns will strengthen your image of yourself as a person who is healthy, abstinent, and recovering: Have you seen a doctor for a
Do you wear the same
checkup?
clothes you wore when you
When was the last time you went to the dentist? Have you considered getting
were using/gambling? Do you need to have your vision or hearing checked?
a new look?
Do you exercise regularly?
Are you paying attention to
Is your caffeine or nicotine
what you are eating?
intake out of control?
Some people find it is easier to make sweeping lifestyle changes all at once. However, if addressing all these health and grooming issues at once is too overwhelming, work on one or two items each week. Decide which are the most important, and do those first. As you look and feel better, you will increase both the strength and the pleasure of your recovery.
The first thing I need to do to take care of myself is:
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RP 18
Trigger
Emotional Triggers
Use
Thought
For many people certain emotional states are directly connected
Craving
to substance use or gambling, almost as if the emotion causes the substance use/gambling. It seems to people in recovery that if they could avoid ever feeling those emotions (for example, loneliness, anger, feeling deprived), they would never relapse. These emotional triggers should act as warnings or “red flags” for clients. The most common negative emotional triggers are the following:
Loneliness: It is difficult to give up friends and activities that are part of a substanceusing or gambling lifestyle. Being separated from friends and family leaves people feeling lonely. Often friends and family members who do not use or gamble are not ready to risk getting back into a relationship that didn’t work earlier. The person in recovery is stranded between groups of friends. The feeling of loneliness can drive the person back toward using/gambling.
Anger: The intense irritability experienced in the early stages of recovery can result in floods of anger that act as instant triggers. A person in that frame of mind is only a few steps from substance use/gambling. Once a person uses/gambles, it can be a long trip back to a rational state of mind.
Feeling Deprived: Maintaining abstinence is a real accomplishment. Usually people in recovery feel justifiably good and proud about what they have been able to achieve. Sometimes people in recovery feel as if they have to give up good times and good things. Recovery seems like a jail sentence, something to be endured. This reverses the actual state of recovery: substance use or gambling begins to look good and recovery seems bad. This upside-down situation quickly leads to relapse. It is important to be aware of these red flag emotions. Allowing yourself to be flooded with these powerful negative emotions is allowing yourself to be swept rapidly toward relapse.
Have some of these emotional states been a trigger for you in the past? Which ones?
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RP 18
Emotional Triggers
Are there other negative emotional states that are dangerous for you? What are they?
One of the goals during the recovery process is learning to separate thoughts, behaviors, and emotions so that you can control what you think and how you behave. It is important to recognize and understand your emotions so that your actions are not always dictated by your feelings. Many people find that writing about their feelings is a good way to recognize and understand their emotions. You don’t need to be a good writer to use this tool. People who do not like to write and who have never written much in the past still can learn valuable things about themselves by putting their feelings into words. Follow the simple instructions, and try a new way of getting to know yourself: 1.
Find a private, comfortable, quiet place and a time just for writing. Try to write each day, even if you can write only for a few minutes.
2.
Begin by taking several deep breaths and relaxing.
3.
Write in a response to a question that you have asked yourself about your feelings (for example, “What am I feeling right now?” “Why am I angry?” “Why am I sad?”).
4.
Forget spelling and punctuation; just let the words flow.
Writing about your feelings makes them clearer to you. It also can help you avoid the emotional buildup that often leads to relapse.
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RP 19
Illness
Getting sick often predicts a relapse. This might seem strange, even unfair. After all, you can’t really do anything about getting sick, right? Many people get a few colds a year. Although you may not be able to prevent yourself from getting sick, you can be aware of the added relapse risk that comes with illness, and you can take precautions to avoid getting sick.
Sickness as Relapse Justification Illness can be a powerful relapse justification. When you are sick, you make a lot of exceptions to your regular routine. You stay home from work; you sleep more than usual; you eat different foods. You may feel justified in pampering yourself (for example, “I’m sick, so it’s OK if I watch TV and lie around most of the day”; “I don’t feel good— I deserve a few extra cookies”). Because people feel that getting sick is out of their control, it seems OK to take a break from their regular behaviors. You need to be careful that, while you are taking a break from other routines, you don’t allow sickness to be an excuse for using/gambling.
Relapse Risks During Illness When you are sick, you are physically weaker. You also may have less mental energy to maintain your recovery. In addition to lacking the energy to fight your substance use disorder or gambling, you may face the following relapse risks when you are sick: Missing treatment sessions Missing mutual-help meetings Not exercising The following relapse risks also can act as triggers when you’re sick: Spending a lot of time alone
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RP 19
Illness
Recovering in bed (which reminds some people of recovering from using) Having a lot of unstructured time
Healthful Behaviors Although you can’t always prevent yourself from getting sick, you can do things to minimize your chances of getting sick. The following behaviors help support your recovery in general and help keep you healthy: Exercise regularly (even when you feel as if you’re getting sick, light exercise can be good for you). Eat healthful meals. Get adequate sleep. Minimize stress. Early in recovery from substance use/gambling, you also should avoid activities that put your health at risk or require recovery time. Elective surgery, serious dental work, and extended exertion may leave you fatigued and make you susceptible to illness.
Recognize When You’re at Risk Because you may be more likely to relapse when you’re sick, you should be alert for the signs of illness. Soreness, tiredness, headaches, congestion, or a scratchy throat can signal the onset of illness. Even something like premenstrual syndrome (PMS) can weaken you physically and make relapse more likely. If you do get sick, try to keep the negative effects of illness from interfering with your recovery by getting well as quickly as possible. Get proper rest and medical attention so that you can return to your regular recovery routine as soon as possible. You will feel stronger, and your recovery will be stronger.
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RP 20
Recognizing Stress
Stress is a physical and emotional response to difficult or upsetting events, particularly those that continue for a long time. Stress is the experience people have when the demands they make on themselves or those placed on them disrupt their lives. Sometimes we are unaware of this emotional state until the stress produces physical symptoms. Place a checkmark next to any of the following problems you
have experienced in the past 30 days: Sleep problems (for example, difficulty falling asleep, waking up off and on during the night, nightmares, waking up early and being unable to fall back to sleep) Headaches
Irritability
Stomach problems
Difficulty concentrating
Chronic illness
General dissatisfaction with life
Fatigue
Feeling overwhelmed
Moodiness If you checked two or more of these items, you may need to make some changes in your life to reduce the level of stress. Becoming more aware of stress is the first step to reducing it. You may have been accustomed to turning to substance use or gambling in times of stress. Learning new ways to cope with stress is part of the recovery process. Another Relapse Prevention session will address techniques for reducing stress.
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RP 21
Relapse Justification II
Once a person decides not to use drugs or gamble anymore, how does that person end up using/gambling again? Do relapses happen completely by accident? Or are there warning signs and ways to avoid relapse? Relapse justification is a process that happens in people’s minds. A person may have decided to stop using/gambling, but the person’s brain is still healing and still feels the need for the substances or gambling. The addicted brain invents excuses that allow the person in recovery to edge close enough to relapse situations that accidents can happen. You may remember a time when you intended to stay drug free or to not gamble but you invented a justification for using/gambling, and before you knew it, you had used or gambled again. Understanding and anticipating the justifications help you interrupt the process. Use the questions below to help you identify justifications you might be susceptible to.
Substance Dependence/Gambling Is Cured Has your addicted brain ever convinced you that you could use or gamble just once or use just a little? For example, have you said any of the following? I’m back in control. I’ll be able to stop when I want to. I’ve learned my lesson. I’ll only use o r g a m b l e small amounts and only once in a while. This substance/gambling was not my problem—stimulants were. So I can use this and not relapse. Other:
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RP 21
Relapse Justification II
Testing Yourself It’s very easy to forget that being smart, not being strong, is the key to staying abstinent.
Have you ever wanted to prove you could be stronger than drugs or gambling? For example, have you said any of the following? I’m strong enough to be around it now. I want to see whether I can say “No” to drinking, using or gambling. I want to see whether I can be around my old friends. I want to see how the high feels now that I’ve stopped using or gambling. Other:
Celebrating You may be encouraged by other people or your addicted brain to make an exception to your abstinence. Have you ever tried to justify using with the following
thoughts? I’m feeling really good. One time won’t hurt. I’m on vacation. I’ll go back to not using or gambling when I get home. I’m doing so well. Things are going great. I owe myself a reward. This is such a special event that I want to celebrate. Other: What might you do when confronted with these excuses to use/gamble?
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RP 22
Reducing Stress
Answering the following questions as honestly as possible will help you identify which parts of your daily living are most stressful. Take steps to correct these problems, and you will reduce stress in your life.
1. In deciding how to spend your time, energy, and money, you determine the direction of your life. Are you investing them in work and hobbies that you find No rewarding? Yes If not, how might you change this?
2. Focusing on the present means giving your attention to the task at hand without past and future fears crippling you. Are you usually able to stay in the here and No now? Yes If not, what prevents you from focusing on the present? How can you change the situation?
3. Do you take time each day to do something relaxing (for example, playing with your children, taking a walk, reading a book, listening to music)? Yes No If not, what relaxing activity will you add to your day?
4. Are you challenging yourself to do things that increase self-confidence? Yes No If not, what changes could you make to boost your self-confidence?
5. Do you tackle large goals by breaking them into smaller, more manageable No tasks? Yes If not, how do you think breaking goals into smaller steps would help you manage stress?
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RP 22
Reducing Stress
6. Are you careful to make your environment (home, workplace) peaceful, whenever possible? Yes No If not, how can you make your environment more peaceful?
No 7. Can you and do you say “No” when that is how you feel? Yes If not, how do you think saying “No” could help you cope with stress in your life?
8. Do you know how to use self-relaxation techniques to relax your body? Yes No If not, what can you do to learn more about ways to relax?
9. Are you careful to avoid large swings in body energy caused by taking in No excess sugar and caffeine? Yes If not, what changes can you make to limit your intake of sugar and caffeine?
10. Are there specific ways you cope with anger to get it out of your system? Yes If not, how would reducing anger help you No manage stress?
11. What techniques can you start using that will help you get rid of anger?
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RP 23
Managing Anger
Anger is an emotion that leads many people to relapse. This is particularly true early in treatment. Frequently, anger slowly builds on itself as you constantly think about things that make you angry. Sometimes it seems that the issue causing the anger is the only important thing in life. Often a sense of victimization accompanies the anger. Do the following questions
seem familiar to you? Why do I get all the bad breaks?
Why won’t he just do what I want him to do?
How come she doesn’t understand my needs? How do you recognize when you are angry? Does your behavior change? Do you notice physical changes (for example, pacing, clenching your jaw, feeling restless or “keyed up”)? How do you express anger? Do you hold it in and eventually explode? Do you become sarcastic and passive–aggressive? What positive ways do you know to cope with anger? Here are some alternative ways to cope with anger. Which of the following will
work for you? Talk to the person you are angry with. Talk to a counselor, a 12-Step sponsor, or another person who can give you guidance. Talk about the anger in an outside support group meeting. Write about your feelings of anger. Exercise. Other:
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RP 24
Acceptance
“Just say no” is good advice to stop people from trying drugs or gambling. But it does not help people who are substance or gambling dependent. Overcoming substance/gambling dependence requires that you recognize its power and accept the personal limitations that occur because of it. Many people accept the hold that substance/gambling dependence has over them when they enter treatment. But entering treatment is the first act of accept- ance. It cannot be the only one. Recovery is an ongoing process of accepting that substance/gambling dependence is more powerful than you are. Accepting that dependence on drugs or gambling has power over you means accepting that human beings have limits. Refusal to accept a substance use or gambling disorder is one of the biggest problems in staying drug/gambling free. This refusal to give in to treatment can lead to what is called “white-knuckle abstinence”— hanging on to abstinence desperately because you isolate yourself and refuse to accept help. Admitting that you have a problem and seeking help are not weaknesses. Does getting treatment for diabetes or a heart condition mean you are a weak-willed person? Accepting the idea that you have a substance use or gambling disorder does not mean you cannot control your life. It means there are some things you cannot control. One of them is the use of drugs/gambling. If you continue to struggle with trying to control the disorder, you end up giving it more power. There is a paradox in the recovery process. People who accept the reality of substance/gambling dependence to the greatest degree benefit the most in recovery. Those who do not fight with the idea that they have a substance use or gambling disorder are the ones who ultimately are most successful in recovery. The only way to win this fight is to surrender. The only way to be successful in recovery and get control of your problem is first to admit that it has control over you.
YOU DO NOT NEED TO “HIT BOTTOM” TO BEGIN RECOVERY.
I have a substance use disorder.
yes
I hope someday I can use again.
Yes
I have a gambling problem
Yes
No No
I need to work on acceptance of
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RP 25
Making New Friends
A blessed thing it is for any person to have a friend: One human soul whom we can trust utterly, who knows the best and worst of us, and who loves us in spite of our faults.
Anonymous Relationships are very important to the recovery process. Friends and family can offer strength and help us understand who we are. The relationships you establish can support or weaken recovery. It has been said, “You will become like those people with whom you spend your time.” Use the following questions to help you think about your friendships.
Do you have any friends like the one described in the poem above? If yes, who are they?
Have you become like the people around you? In what ways?
What is the difference between a friend and an acquaintance?
Where can you make some new acquaintances who might become friends?
To whom are you a friend?
What behaviors do you need to change to be better able to have honest relationships?
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RP 26
Repairing Relationships
Friends and family of people who are substance or gambling dependent often get hurt as a result of the substance abuse or problem gambling. People who are substance/gambling dependent often cannot take care of themselves and certainly cannot take care of others. As part of your recovery, you should think about whom you have hurt. You should also think about whether you need to do anything to repair the relationships that are most important to you. In 12-Step programs this process is called “making amends.”
What are some of the past behaviors you might want to amend?
Are there things you neglected to do or say when you were using/gambling that should be addressed now? How are you planning to make amends?
Do you feel that being in recovery and stopping the use of drugs/gambling is enough?
Making amends does not have to be complicated. Acknowledging the hurt you caused while you were using substances/gambling will probably help reduce conflict in your relationships. Not everyone will be ready to forgive you, but an important part of this process is beginning to forgive yourself. Another aspect of repairing relationships involves your forgiving others for things that they did when you were using substances or gambling.
Whom do you need to forgive? What resentments do you need to let go of?
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RP 27
Serenity Prayer
God grant me the serenity to accept the things I cannot change, The courage to change the things I can, And the wisdom to know the difference.
What does this saying mean to you?
How can you find meaning in this saying, even if you are not religious or don’t believe in God?
What parts of your life or yourself do you know you cannot change?
What have you changed already?
What parts of your life or yourself do you need to change?
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RP 28
Compulsive Behaviors
Many people who are substance or gambling dependent enter treatment just to stop using a certain drug or stop gambling. They do not intend to change their lives entirely. When they enter treatment, they are told that recovery requires making other changes in the way they live. The lifestyle changes put people in recovery back in control of their lives.
In what ways was your life out of control before you entered treatment?
Have you noticed yourself behaving excessively in any of the following ways? Working all the time
Eating foods high in sugar
Abusing prescription medications
Exercising to the extreme
Using illicit drugs other than the one you entered treatment for
Gambling
Drinking a lot of caffeinated sodas or coffee
Masturbating compulsively Spending too much money Other:
Smoking What changes have you tried to make so far?
Does the following sound familiar? “I stopped smoking and using drugs. It was hard. Then one day I gave in and had a cigarette. I felt so bad that I had messed up, I ended up using.” This pattern is called the “abstinence violation syndrome.” Once you compromise one part of your recovery, it becomes easier to slide into relapse.
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RP 28
Compulsive Behaviors
Do you have a similar story from the past? What event led to your relapse?
What major lifestyle changes are you making in recovery?
Is it uncomfortable for you to make these changes?
Yes
No
Are you avoiding being uncomfortable by switching to other compulsive behaviors? If so, what are they? Are there changes you still need to make? If so, what are they?
Relapse and Sex Like substance use and gambling, high-risk sex is controlled by a trigger process. (High-risk sex includes sex with a stranger, unprotected sex, and trading sex for drugs or engaging in sex to get money for gambling.) Triggers lead to thoughts of sex. Thoughts of sex lead to arousal and action. For many people, high- risk sex is associated with substance use or gambling. High-risk sex can be a trigger for substance use or gambling. Engaging in high-risk sex can bring on a relapse to substance use/gambling.
What are some of your triggers for substance use? What are some of your triggers for gambling? What are some of your triggers for high-risk sex? Have you experienced a relapse when sex was a trigger to use/gambling?
Prevention Once you are aware of the things that are triggers for you, you can take steps to prevent a relapse. Here are some suggestions you can do to prevent a relapse:
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RP 28
Compulsive Behaviors
Prevent exposure to triggers. Stay away from people, places, and activities that you associate with drug use/gambling.
Stop the thoughts that may lead to relapse. Many techniques can be used to do this. Some examples of thought-stopping techniques are the following:
Relaxation—Take three slow, deep breaths. Snapping—Wear a rubberband loosely on your wrist and every time you become aware of a triggering thought, snap the rubberband and mentally say, “No!” to the thought.
Visualization—Imagine an ON/OFF switch in your head. Turn it to OFF to stop the triggering thoughts.
Schedule your time. Structure your day and fill blocks of free time with activities. You can exercise, do volunteer work, or spend time with friends who do not use drugs or gamble.
Break your typical pattern. Take a trip out of town. Go to a movie or watch a video. Go out to eat. Go to a 12-Step or mutualhelp meeting at a time you normally would be doing something else.
What are some other things you could do to prevent a relapse?
What do you plan to do next time you’re aware of being in a relapse situation?
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RP 29
Coping With Feelings and Depression
Feelings Can You Recognize Your Feelings? Sometimes people don’t allow themselves to have certain emotions (for example, you tell yourself, “Feeling angry is not all right”). Sometimes people aren’t honest with themselves about their emotions (for example, saying, “I’m just having a bad day,” when the truth is they’re sad). When you mislabel emotions or deny them, you cannot address them and they build up inside you.
Are You Aware of Physical Signs of Certain Feelings? Maybe you get an upset stomach when you are anxious, bite your fingernails when you are stressed, or shake when you are angry. Think about the emotions that trouble you, and try to identify how they show physically.
How Do You Cope With Your Feelings Now? How do you respond when you experience negative emotions? How do your feelings affect you and others around you? For instance, do your feelings interfere with your relationships with others? Do people avoid you, try to keep you from getting upset, or try to make you feel better? Focus on one or two emotions you need to cope with better.
How Do You Express Your Emotions? It is important to find an appropriate way to express emotions. You can express feelings indirectly (to a trusted group, friend, or counselor), or you can express feelings directly to others about whom you have the feelings. You need to learn in which situations it is appropriate to express feelings directly. You also can change your thinking in ways that result in your feeling different. For example, instead of saying, “I am so angry she doesn’t agree with me, I feel like using/gambling,” you can frame your feelings as, “It’s all right for someone not to agree with me, and using will not make anything better.” Do not let out-of-control feelings drive you back to using or gambling. Learning to cope with emotions means allowing yourself to feel and balancing an honest response with intelligent behavior.
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RP 29
Coping With Feelings and Depression
Depression Although we know drug use, gambling and depression are related, it is not always clear how they interact. Most people in recovery report having problems with depression from time to time. Depression can be a particular problem for people who have been using stimulants or gambling. Stimulants and gambling make people feel “high” by flooding the brain with chemicals called neurotransmitters that regulate feelings of pleasure. During recovery there are periods when the brain doesn’t supply enough of those neurotransmitters. The undersupply of neurotransmitters causes a temporary feeling of depression. But this is different from being clinically depressed. For some people, depression left untreated can result in relapse. It is important to be aware of signs of depression and be prepared to cope with the feelings. If you feel that you cannot cope with your depression or if your depression lasts for a long time, seek help from a mental health professional. Your counselor or someone else at your treatment program can refer you to someone for help. These are some symptoms that might indicate depression. Check all that apply to you:
Low energy
Stopping exercise program
Overeating or not eating
Avoiding social activities
Sad thoughts
Feelings of boredom, irritability, or anger
Losing interest in career or hobbies
Crying spells
Sleeping more than usual
Suicidal thoughts or actions
Decreased sex drive
Stopping normal activities such as work, cleaning house, buying groceries
Increased thoughts of drinking/gambling Insomnia Stopping attendance at 12-Step or mutual-help meetings
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Coping With Feelings and Depression
What other signs indicate depression?
Responses to depression include the following: Increase exercise.
Talk to a spouse.
Plan some new activities.
Talk to a friend.
Consult a doctor; medication
Talk to a counselor.
may help.
Do you have any other ways of coping effectively with depression?
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RP 30
12-Step Programs
What Is AA? Alcoholics Anonymous (AA) is a worldwide organization. It has been in existence since the 1930s. It was started by two men who could not recover from their alcoholism with psychiatry or medicine. AA holds free, open meetings to help people who want to stop being controlled by their need for alcohol. Meetings are available throughout the day and evening, 7 days a week. The principles of AA have been adapted to help people who are dependent on drugs or who have other addictive disorders, such as gambling or overeating.
Are These Meetings Like Treatment? No. They are groups of people in recovery helping one another stay abstinent.
Does a Person Need To Enroll or Make an Appointment? No, just show up. Times and locations of meetings are available through this treatment program or by calling AA directly.
What Are the 12 Steps? The basis of groups such as AA is the 12 Steps. These beliefs and activities provide a structured program for abstinence. There is a strong spiritual aspect to both the 12 Steps and AA.
The 12 Steps of Alcoholics Anonymous* 1.
We admitted that we were powerless over alcohol—that our lives had become unmanageable.
2.
Came to believe that a power greater than ourselves could restore us to sanity.
* The Twelve Steps are reprinted with permission of Alcoholics Anonymous World Services, Inc. (A.A.W.S.). Permission to reprint the Twelve Steps does not mean that A.A.W.S. has reviewed or approved the contents of this publication, or that A.A.W.S. necessarily agrees with the views expressed herein. A.A. is a program of recovery from alcoholism only—use of the Twelve Steps in connection with programs and activities which are patterned after A.A., but which address other problems, or in any other non-A.A. context, does not imply otherwise.
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RP 30 3.
12-Step Programs
Made a decision to turn our will and our lives over to the care of God, as we understood Him.
4.
Made a searching and fearless moral inventory of ourselves.
5.
Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6.
Were entirely ready to have God remove all these defects of character.
7.
Humbly asked Him to remove our shortcomings.
8.
Made a list of all persons we had harmed and became willing to make amends to them all.
9.
Made direct amends to such people wherever possible, except when to do so would injure them or others.
10.
Continued to take personal inventory, and when we were wrong, promptly admitted it.
11.
Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry it out.
12.
Having had a spiritual awakening as a result of these Steps, we tried to carry this message to addicts and to practice these principles in all our affairs.
What Are CA, NA and GA? Cocaine Anonymous, Narcotics Anonymous and Gamblers Anonymous. Other 12Step groups include Marijuana Anonymous, Pills Anonymous, Overeaters Anonymous, Emotions Anonymous, and more. Here are the Web site addresses for these support groups:
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12-Step Programs
Cocaine Anonymous (CA): www.ca.org Narcotics Anonymous (NA): www.na.org Gamblers Anonymous (GA): www.gamblersanonymous.org Marijuana Anonymous (MA): www.marijuana-anonymous.org Pills Anonymous (PA): groups.msn.com/PillsAnonymous Overeaters Anonymous (OA): www.oa.org Emotions Anonymous (EA): www.emotionsanonymous.org The methods and principles of the groups are similar although the specific focus differs. Spinoff groups that use the 12 Steps include Al-Anon and Alateen, Adult Children of Alcoholics, Co-Dependents Anonymous, and Adult Children of Dysfunctional Families. Here are the Web site addresses for some of these support groups: Al-Anon and Alateen: www.al-anon.alateen.org Nar-Anon: www.naranon.com Adult Children of Alcoholics (ACoA): www.adultchildren.org Co-Dependents Anonymous (CoDA): www.codependents.org Often people go to more than one type of group. Most people shop around for the type of group and the specific meetings that they find most comfortable, relevant, and useful.
What Is CMA? Crystal Meth Anonymous (www.crystalmeth.org). CMA is a 12-Step group that offers fellowship and support for people who want to stop using meth. CMA meetings are
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12-Step Programs
open to anyone with a desire to end dependence on meth. Like other 12-Step programs, CMA has a spiritual focus and encourages participants to work the 12 Steps with the help of a sponsor. CMA advocates complete abstinence from nonprescribed medication.
What if a Person Is Not Religious? One can benefit from 12-Step or mutual-help meetings without being religious or working the 12 Steps. Many people in 12-Step and mutual-help groups are not religious. These people may think of the higher power mentioned in the 12 Steps as a bigger frame of reference or a bigger source of knowledge than themselves.
What Do 12-Step Programs Offer? A safe place to go during recovery A place to meet other people who don’t use drugs and alcohol A spiritual component to recovery Emotional support Exposure to people who have achieved long-term abstinence A worldwide network of support that is always available It is strongly recommended that you attend 12-Step or mutual-support meetings while you are in treatment. Ask other clients for help in choosing the best meeting for you. Try several different meetings. Be open to the ways that 12-Step meetings can support your recovery: social, emotional, or spiritual.
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RP 31
Looking Forward; Managing Downtime
Islands To Look Forward To There are many important elements to a successful recovery. Structure is important. Scheduling is important. Balance is important. Your recovery works because you work at it. Amid the hard work and the structure of recovery, do you feel as if something is missing? The activities and routines of recovery can seem stifling. Do you feel that you need to take a break from the routine and get excited about something? The emotional flatness you experience during recovery may be explained by the following: Many people feel particularly bored and tired 2 to 4 months into recovery (during the period known as the Wall). The recovery process the body is going through may prevent you from feeling strong emotions of any kind. Life feels less “on the edge” than it did when you were using or gambling. Planning enjoyable things to look forward to is one way to put a sense of anticipation and excitement into your life. Some people think of this as building islands of rest, recreation, or fun. These are islands to look forward to so that the future doesn’t seem so predictable and routine. The islands don’t need to be extravagant things. They can be things like Going out of town for a 3-day weekend Taking a day off work Going to a play or a concert Attending a sporting event Visiting relatives Going out to eat
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RP 31
Looking Forward; Managing Downtime
Visiting an old friend Having a special date with your partner Plan these little rewards often enough so that you don’t get too stressed, tired, or bored in between them.
List some islands that you used to use as rewards.
What are some possible islands for you now?
Handling Downtime The Problem Being in recovery means living responsibly. Always acting intelligently and constantly guarding against relapse can be exhausting. It is easy to run out of energy and become tired and bitter. Life can become a cycle of sameness: getting up, going to work, coming home, lying on the couch, going to bed, and then doing it again the next day. People in recovery who allow themselves to get to this state of boredom and exhaustion are very vulnerable to relapse. It is difficult to resist triggers and relapse justifications when your energy level is so low.
The Old Answer Drugs, alcohol or gambling provided quick relief from boredom and listlessness. All the reasons for not using substances or gambling can be forgotten quickly when the body and mind desperately need refueling.
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Looking Forward; Managing Downtime
A New Answer Each person needs to decide what can replace substance use or gambling and provide a refreshing, satisfying break from the daily grind. What works for you may not work for someone else. It doesn’t matter what nonusing and nongambling activities you pursue during your downtime, but it is necessary to find a way to relax and rejuvenate. The more tired and beaten down you become, the less energy you will have for staying smart and committed to recovery. Notice how often you feel stressed, impatient, angry, or closed off emotionally. These are signs of needing more downtime. Which activities listed below would help
rejuvenate you? Walking Reading Meditating or doing yoga Listening to music Playing with a pet Becoming active in a church Talking with a friend who does not use
Taking a class Playing team sports Bicycling Painting, drawing Exercising at the gym Cooking
Going to the movies Writing Knitting Fishing Scrapbooking Window shopping
Going to 12-Step or mutual-help meetings
Playing a musical instrument
On a day when you’re stressed and you realize that in the past you would have said, “I really need a drink” or “I need to get high or gamble today,” what will you do now? What will you do in your downtime?
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RP 32
One Day at a Time
People in recovery usually do not relapse because they cannot handle one difficult day or one troubling situation. Any given day or any single event usually is manageable. Things become unmanageable when the person in recovery allows events from the past or fears of the future to contaminate the present. Beating yourself up about the past makes you less able to handle the present. You allow the past to make your recovery more difficult when you tell yourself “I can never do anything right. I always mess up every opportunity.” “If I try to do something difficult, I will fail. I always do.” “I always am letting people down. I always have disappointed everyone.” You need to find a way to reject those negative thoughts when they come up. The thought-stopping techniques you learned in Early Recovery Skills (session 1) can help you move past these negative thoughts. Exercise, meditation, and journal writing also help you focus your mind and control your thoughts.
Can you think of a recent situation in which you allowed the past to make the present more difficult?
Don’t allow things that might happen in the future to overwhelm you in the present. You can plan ahead and be prepared, but you can do little else about the unknown. You can address only what is happening right now, today. You are filling yourself with fear when you tell yourself
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RP 32
“Tomorrow something will happen to ruin this.” “That person is going to hate me for this.” “I will never be able to make it.”
What things do you tell yourself that make you fear the future?
When you have these thoughts, it may help to remind yourself of times when you did not let your past behavior influence the future. Think of times when you broke away from an old, destructive pattern. Calling a friend who can remind you of your successes is a good way to keep yourself focused on today and reject fearful thoughts of the future.
What things can you tell yourself that will bring you back to the present?
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Drug and Gambling RP 33 Dreams During Recovery Early Recovery (0–6 weeks) Drug use and gambling interfere with normal sleeping. When people stop using, they experience frequent and intense dreams. This can be true with stopping gambling as well. The dreams seem real and frightening. These dreams are a normal part of the recovery process. You are not responsible for whether you use or gamble in a dream. Regular exercise may help lessen the dream activity.
Middle Recovery (7–16 weeks) For most people, dreams are less frequent during this phase of recovery. When they do occur, however, dreams can leave powerful feelings well into the following day. It is important to be careful to avoid relapse on days following powerful dream activity. Often dreams during this period are about choosing to use or not to use, and they can indicate how you feel about those choices.
Late Recovery (17–24 weeks) Dreaming during this period is very important and can be helpful in warning the person in recovery. Sudden dreaming about drug, alcohol use or gambling can be a clear message that there may be a problem and that the dreamer is more vulnerable to relapse than usual. It is important to review your situation and correct any problems you discover. Listed below are some of the actions people take when their dreams become intense and troubling. Add to the list things that would help you in this situation:
Exercise Go to a 12-Step or mutual-help meeting Call a counselor Talk to friends Take a break from your normal routine Other:
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Date:
Rate how satisfied you are with the following areas of your life by placing a checkmark in the appropriate boxes. Very Somewhat Somewhat Very Dissatisfied Dissatisfied Neutral Satisfied Satisfied
RP Elective A
Name:
Career Friends
Romantic Relationships Drug Use/Cravings Alcohol Use/Cravings Gambling Behavior/Cravings
Self-Esteem Physical Health Psychological Well-Being
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Sexual Fullfillment
Client Status Review
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Family
Spiritual Well-Being
RP Elective A
Client Status Review
Which of these areas improved the most since you entered treatment?
Which are your weakest areas? How are you planning to improve them?
What would need to change for you to be satisfied with the areas you rated lowest?
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RP Elective B
Holidays and Recovery
Holiday seasons and the celebrations that come with them are difficult for people in recovery. Many things can happen to increase the risk of relapse. Review the list
below and check the items that might cause problems for you and your recovery program during the holidays. Then total up the number of checkmarks and assess your relapse risk below: More alcohol and drugs at parties More gambling at parties Shortage of money because of travel or gift buying Not having money for gift buying or travel More stress caused by hectic pace (for example, traffic, crowds) Normal routine of life interrupted Stopping exercise Not going to AA/NA/GA meetings Not going to therapy Party atmosphere More contact with family Increased emotions from holiday memories Increased anxiety regarding triggers and craving Frustration of not having time to meet responsibilities Coping with “New Year ’s Eve” type occasions Extra free time with no structure Feeling lonely or isolated
Other:
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RP Elective B
Holidays and Recovery
Mild: If you checked one to three items, the holidays produce only a slightly increased risk of relapse.
Moderate: If you checked four to six items, the holidays add a lot of stress to your life. Relapse risk is related to how well you cope with increased stress. Your score indicates that you need to plan carefully for your recovery during the holidays.
Severe: If you checked seven or more items, the holidays add a major amount of stress to your life. Relapse prevention means learning how to recognize added stress and taking extra care during dangerous periods. Your score indicates the holidays are one of these periods for you.
NO ONE HAS TO RELAPSE. NO ONE BENEFITS FROM A RELAPSE. THINK ABOUT YOUR RECOVERY PLAN. ADD SOME MEETINGS. SCHEDULE YOUR TIME. SEE YOUR COUNSELOR. TO GET THROUGH THIS STRESSFUL TIME, USE THE TOOLS THAT HAVE HELPED YOU STAY ABSTINENT IN RECOVERY.
NO ONE HAS TO RELAPSE!
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RP Elective C
Recreational Activities
In addition to abstaining from substance use or gambling, it is important for you to put some interesting activities in your life. For many people in recovery, substance use or gambling was the main thing they did to relax and have a good time. Now that you are abstinent and in recovery, it is important to find fun things to do that can take the place of substance use/gambling. You might try returning to old activities you used to enjoy before you started using substances or gambling.
What are some hobbies or activities that you used to enjoy and might like to try again?
New activities and hobbies are an excellent way to support your recovery while you meet new people. Now is the time to take a class, learn a new skill, try your hand at making art, take up a new sport, do volunteer work, or try out other new interests. Ask your friends about hobbies that they enjoy. See about adult classes that are offered at local colleges. Consult your local community’s directory or Web site for listings of activities and classes. Check the newspaper for lectures, movies, plays, and concerts.
What new activities and interests would you like to pursue?
It is important to remember that not all new activities will be fun right away. It may take a while before you can really enjoy a new activity or become proficient at a new skill. Old activities that you enjoyed may not feel the same now that you’re abstinent and in recovery. Regardless of how new or old activities feel, you need to make them part of your life.
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DHHS Publication No. (SMA) 07-4154 U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration
